Family Practice, 2016, Vol. 33, No. 3, 261–267
doi:10.1093/fampra/cmw013
Advance Access publication 21 March 2016
Health Service Research
Mapping primary health care renewal in South
America
Naydú Acosta Ramíreza,*, Ligia Giovanellab, Roman Vega Romerob,c,
Herland Tejerina Silvad, Patty Fidelis de Almeidae, Gilberto Ríosf,
Hedwig Goedeg and Suelen Oliveirah
Department of Public Health, Pontificia Universidad Javeriana, Cali, Colombia, bDepartment of Administration
and Planning in Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, cPublic
Health Institute, Pontificia Universidad Javeriana, Bogotá, Colombia, dFaculty of Medicine, Universidad Mayor de
San Andrés, La Paz, Bolivia, eDepartment of Health Planning, Fluminense Federal University, Niterói, Brazil, fFaculty
of Medicine, Universidad de la República, Montevideo, Uruguay, gGoede Public Health Cons Bureau, Independent
Advisor, Paramaribo, Suriname and hFaculty of Psychology, Centro ABEU University, Rio de Janeiro, Brazil.
a
*Correspondence to Naydú Acosta Ramírez, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Calle 18
No. 118-250, Cali, Colombia; E-mail: [email protected]
Abstract
Background. Primary health care (PHC) renewal processes are currently ongoing in South America
(SA), but their characteristics have not been systematically described.
Objective. The study aimed to describe and contrast the PHC approaches being implemented in
SA to provide knowledge of current conceptions, models and challenges.
Methods. This multiple case study used a qualitative approach with technical visits to health
ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53
local managers, as well as field observation of 57 selected PHC providers and document analysis,
using a common matrix for data collection and analysis. PHC approaches were analysed by
triangulating sources using the following categories: PHC philosophy and conception, service
provision organization, intersectoral collaboration and social participation.
Results. Primary health care models were identified in association with existing health system
types and the dynamics of PHC renewal in each country. A neo-selective model was found in
three countries where coverage is segmented by private and public regimes; here, individual and
collective care are separated. A comprehensive approach similar to the Alma-Ata model was found
in seven countries where the public sector predominates and individual, family and community
care are coordinated under the responsibility of the same health care team.
Conclusions. The process of implementing a renewed PHC approach is affected by how health
systems are funded and organized. Both models face many obstacles. In addition, care system
organization, intersectoral coordination and social participation are weak in most of the countries.
Key words. Comprehensive health care, health care reform, primary health care, social participation, South America, universal coverage.
Introduction
Given the persistent challenges of health inequality and premature
mortality in the region of the Americas (1), there is growing interest in implementing systems and models of health care capable of
© The Author 2016. Published by Oxford University Press. All rights reserved.
For permissions, please e-mail: [email protected].
yielding improvements in the health of populations, which is not a
recent concern.
In 1978, the Declaration of Alma-Ata reiterated that health is
a fundamental human right that must be respected, protected and
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262
guaranteed to all the world’s peoples. It set out to establish a concept
of primary health care (PHC) strategy framed by a model in which
care is comprehensive and inseparable from economic, social and
cultural development, and involves health promotion, social participation and intersectoral cooperation to address the social determinants of health. Nonetheless, in the 1980s and 1990s, in many
countries focalized, selective models of PHC delivered by vertical
programs targeting vulnerable population groups or specific health
problems were developed. Since the 1990s, encouraged and financed
by multilateral finance agencies, some countries have carried out
health sector reforms with a market-economy approach centred
on competition and cost control, managed care, health insurance,
separation of individual and collective health risk management and
limited health benefit packages or focused insurance for marginal
population groups. These reforms have worsened social inequities
and the fragmentation of care and, by centring interventions on the
health sector, they have limited the reach of intersectoral action and
community participation (2).
Meanwhile, several studies have found improvements in health
indicators associated with the implementation of PHC (3,4)
as recommended at Alma-Ata. As a result, since 2005, the Pan
American Health Organization and subsequently the World Health
Organization have urged their member states to renew PHC with
universal coverage, promote equity in health and guarantee the universal right of access to health services.
Primary health care renewal processes are currently ongoing in
South America (SA), but their characteristics have not been examined systematically. Accordingly, this article aims to describe the
PHC approaches being implemented in the 12 countries of SA. It
aims to provide knowledge of current PHC conceptions, models and
challenges in the region by contrasting experiences so as to identify
and understand shared problems and the possible solutions encountered in each country. The latter may, in turn, serve to guide national
or regional policies towards building universal coverage systems and
comprehensive models of health care.
Methods
On a multiple case study approach, PHC was mapped in Argentina
(5), Bolivia (6), Brazil (7), Chile (8), Colombia (9), Ecuador (10),
Guyana (11), Paraguay (12), Peru (13), Suriname (14), Uruguay (15)
and Venezuela (16). A qualitative approach was applied, starting
with definition of theoretical categories and application of multiple
data and information collection strategies. The fieldwork for data
collection included 12 meetings at health ministry offices, developing key-informant interviews of 129 PHC national policy makers
and 53 local managers, field observation of 57 selected PHC services
between November 2013 and April 2014, document analysis and a
literature review. The complete information sources by country are
available in the case study reports (5–16).
Information from the various sources was triangulated and analysed critically on the basis of the predefined matrix categories and
emerging empirical categories. The results were first presented in
country case study reports (5–16), which describe the components
of PHC implementation in the region. This article draws on those
mappings to characterize the PHC approaches in terms of selected
theoretical categories considered core components of comprehensive PHC. The selected categories are as follows: key elements of
the PHC model (PHC philosophy and conception in health policies), organization of service provision (PHC team composition,
territorialization and integration with other levels of health care),
intersectoral cooperation (interaction with other public policy sectors at the national level to address the social determinants of health)
and social participation (forms of user representation and participation in PHC). Based on the qualitative analysis process by triangulating among sources (17), the results contrast the experiences of each
country and identify common elements in PHC implementation in
relation to existing health system types and segmentation of population coverage. Another study describes other categories and variables examined in the PHC mapping in the countries of SA, such as
the responsibilities and attributions of levels of government in PHC
implementation, funding and intercultural approaches (18).
Mapping in the 12 countries was coordinated and funded by
the South American Institute of Government in Health (ISAGS), an
international organization of the Health Council of the Union of
South American Nations (UNASUR).
Results
The elements of philosophy and conceptions formally defined in legislation or official documents of health policies in South American
countries are shown in Table 1. The commitment to PHC is highlighted in the policy documents in all South American countries.
With different approaches, the national policies incorporate the main
elements of the Alma Declaration. All countries mention comprehensive care and seven countries describe a new care model (Table 1).
Three countries (Bolivia, Ecuador and Venezuela) also make a priority of health promotion, understood as intersectoral action on the
social determinants of health, plus social and community participation. In some countries, there is an emphasis on interculturalism,
including respect and assimilation of the know-how and practices
of Indigenous peoples. Examples are the ‘Modelo de Salud Familiar
Comunitario Intercultural’ in Bolivia (6), the ‘Modelo de Atención
Integral en Salud Familiar Comunitaria e Intercultural’ in Ecuador
(10), the intercultural PHC model among the Mapuche in Chile (8)
and the ‘Sistema Indígena Propio e Intercultural’ in Colombia (9).
In most countries, the PHC provision is organized on the basis of
two health facility types: posts and centres. Health posts serve small,
rural, dispersed populations and are generally staffed by nursing auxiliaries or community health workers (CHWs) (18). Health centre
teams (Table 2) commonly comprise a doctor, a nurse, nursing auxiliaries and sometimes a midwife, social assistant, dentist and dental
assistant. There are team variations within and between countries.
Sometimes, the teams are incomplete due to an insufficient supply
of health professionals. In six countries (Argentina, Chile, Guyana,
Paraguay, Peru and Uruguay), PHC teams include nurse-midwives,
midwives or obstetrics graduates. In other cases (for example, in
Venezuela and in Bogotá, the capital city of Colombia), there are
complementary teams comprising other health professionals, such
as psychologists, social workers and environmental technicians. In
nearly all the countries, PHC teams include paid or volunteer CHWs
to liaise between community and health services and perform extramural and community tasks.
The supply of health professionals varies among countries, and
its internal distribution is extremely uneven. Even though no consistent statistics are available on PHC human resources, the consensus is
that they are insufficient in number and their education and training
are inappropriate (i.e., not specifically designed for PHC activities).
In nearly all the countries, there is a range of new PHC training initiatives at all levels (technical, undergraduate, postgraduate and continuous professional development). Nine countries (Bolivia, Brazil,
Chile, Ecuador, Guyana, Peru, Suriname, Uruguay and Venezuela)
Mapping primary health care renewal
263
Table 1. Elements of primary health care model (PHC philosophy and conception in health policies in South American countries)
Countries
Conceptions of PHC in present policy
Argentina (2004)
Health is considered a right, the responsibility of the state. Emphasis is on comprehensive care, disease prevention, health
promotion and rehabilitation, accessibility and health service decentralization. This gives the framework for various initiatives, including the ‘Remediar’ and ‘Médicos Comunitarios’ (PMC) programs (5).
With its principles of community participation, intersectoral collaboration, interculturalism and comprehensive care, the
‘Modelo de Salud Familiar Comunitario Intercultural’ (SAFCI) comprises the elements of comprehensive PHC (6).
The ‘Política Nacional de Atenção Básica’ conceives comprehensive care as a set of actions for individual and collective
health, which are to affect the health situation, people’s autonomy and the social factors that determine and condition
collective health. The ‘Estrategia de Salud de la Familia’ (ESF), with its multi-profession teams, territorial basis and social
participation emphasis, is the main PHC delivery model (7).
The ‘Modelo de Atención Integral de Salud, Familiar y Comunitaria’ emphasizes the equitable distribution of health care
resources so as to deliver essential health care in keeping with the Alma-Ata recommendations, with a biopsycho-social, user-centred approach. Features include integrated care, continuity, intersectoral cooperation, promotion and
prevention, participation in health care, use of appropriate technology and quality (8).
PHC is defined normatively (Law 1438) as a national strategy for intersectoral coordination to permit comprehensive,
integrated care, extending from public health through health promotion, disease prevention, diagnosis, treatment and
rehabilitation, at all levels of complexity (9).
Since the 2008 constitution, PHC has been specified as the base of the health system, grounded in comprehensive family
and community care, interconnecting the various levels of care and fostering complementation with ancestral and alternative medicine. The ‘Modelo de Atención Integral en Salud Familiar Comunitaria e Intercultural’ (MAIS-FCI) incorporates
the renewed PHC approach and states that it is the set of strategies that organises the National Health System in order to
meet the health needs of individuals, families, communities and environs (10).
The document ‘Visión de Salud 2020’ reaffirms the commitment to PHC and the importance of addressing the social determinants of health. The health system is based on PHC; universal access to free health care is a constitutional right (1980)
and the emphasis is on health promotion and comprehensive care at the various levels of complexity (11).
PHC is understood as a strategy that comprehensively comprises the health–illness process and care for individuals and
communities, with regard for their differing life stages. It provides health services and addresses the social, economic, political and environmental root causes of ill health. Family health teams and facilities are assigned to specific territories in order
to increase access by excluded population groups (12).
The ‘Modelo de Atención Integral de Salud Basado en la Familia y la Comunidad’ (MAIS-BFC) rests on the Alma-Ata
definition of PHC and the principles, values and strategies of renewed PHC, emphasizing promotion and prevention,
integration of public health services and personal care, development of a family- and community-directed orientation and
service quality improvement (13).
The national development plan ‘Suriname in Transformation 2012–2016’ assigns PHC the role—key to equity in health
and requiring multi-sector collaboration and social participation—of addressing social determinants, which are strategic
for dealing with chronic non-communicable diseases (14).
Law 18.211, which institutes the Integrated National Health System, stipulates PHC as its strategy. Networks will be organized by levels of care, prioritizing the primary level, which will comprise a set of comprehensive, health sector activities
directed to individuals, families, communities and the environment, to meet basic health needs and improve quality of life,
to appropriate levels of resolution, with the participation of the human unit involved (15).
Set up in 2004, the ‘Barrio Adentro’ mission explicitly makes PHC its fundamental strategy and stipulates that it is an
integral part of both the National Public Health System and of overall community social and economic development. It
constitutes the first level of contact between individuals, family and community with the National Public Health System.
The mission stresses accessibility, continuity and integration among the different levels of care and related networks, to
guarantee that health needs are met in a timely, regular and sufficient manner (16).
Bolivia (2008)
Brazil (2006, 2011)
Chile (2005, 2013)
Colombia (2011)
Ecuador (2008, 2012)
Guyana (2013, 2010)
Paraguay (2008)
Peru (2003, 2011)
Suriname (2012)
Uruguay (2007)
Venezuela (2004, 2014)
Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).
maintain cooperation agreements with Cuba to address the undersupply of doctors for PHC.
One of the main problems in retaining doctors in public PHC
services lies in labour regulations. Employment relations and remuneration arrangements in PHC vary across all the countries. There
is a tendency towards more flexible and less stable labour relations,
including temporary, fixed-term contracts with fewer civil servants
in indefinite-term, budgeted positions. Instability of labour contracts
and lower salaries in the public sector hinder adhesion and prevent
the formation of bonds among the health team, families and community. Chile is the only country with a civil service career in PHC.
In most of the countries, PHC services are territorialized, with
user population allocation and health teams responsible for a specific, geographically defined target population (Table 2). The number of general population assigned per team varies from 1250
(Venezuela) to 3000 (Brazil) and 5000 (Chile). Community health
situation diagnosis and family records are not always in systematic use, although they are recommended as instruments for identifying socio-economic and health conditions to guide health team
responses in the community.
Integration of PHC with other health care providers, such as
those involved in secondary/specialist care, is a concern of policy
makers; in addition, in all the countries, primary-level services are
increasingly defined as the system gateway or the first-contact service, and the PHC team is considered the gatekeeper for access
to specialized care. Nonetheless, officials recognize difficulties in
accessing specialized care, and they also realize that specialized and
emergency services are still often used for non-severe cases. Because
of short public supply, waiting times for specialized services are long,
but are almost never monitored or made public.
Family Practice, 2016, Vol. 33, No. 3
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Table 2. Organization of primary health care service provision in South American countries
Countries Composition of basic PHC teams at health centres
(‘Centros de Salud’)
PHC services territorialized:
catchment area and population
assignment
Number of general population
assigned per team
Argentina Medical doctors, nurse, nursing auxiliaries, midwives,
dentists, paid CHWs
Bolivia
Medical doctor, dentist, nursing auxiliary/technician,
volunteer CHWs
Brazil
Family health team: medical doctor, nurse, 1–2 nursing
auxiliaries/technicians, 5 or 6 paid CHWs
Oral health teams: dentist, oral health auxiliary and/or
technician
Chile
Medical doctor, nurse, midwife, social assistant and
administrative assistant
Colombia No general rule on team composition. Primary health
teams generally consist of medical doctors, general
nurses, auxiliaries and health technicians, volunteer and
paid CHWs
Ecuador
Medical doctors, nurse and PHC technician (paid CHWs)
Yes, uneven by state
3200–4000
Yes, but allocation is developing
1000–20 000
Yes, population allocated per team
in the Family Health Strategy
3000–4500 per family health team
Yes, population allocated per team;
enrolment is on user initiative
In some municipal models, no national guidelines on sectorization of
PHC centres or user assignment
Up to 5000 per multidisciplinary
team
No general rule; depends on PHC
model in each territorial body
Yes, by circuits and districts; general
population assignment
4000 in urban areas
Guyana
No assignment of users or general
population
Paraguay
Peru
Suriname
Medical doctor, nurse, midwife, laboratory assistant, auxiliary pharmacist, dental assistant, rehabilitation assistant,
environmental health assistant, Medex technician and
paid CHWs
Medical doctor, graduate nurse and/or graduate in
obstetrics, nursing auxiliary and 3–5 paid CHWs. For
every two family health teams, there is a dental team
consisting of a dentist and dental technician
Medical doctor, obstetrics graduate, nurse, nursing
technician, volunteer CHWs
Medical doctor, nurse, health assistant
Uruguay
1500–2500 in rural areas
–
Yes, general population assigned per
family health team
3500–5000 (or 800 families)
Yes, primary health team users are
registered by area of residence at the
closest primary-level health facility
No general population or user assignment
No general population or user assignment
500–800 families assigned per
primary health team
Family or general practitioner, nurse, midwife,
paediatrician and visiting gynaecologist (basic team in
Montevideo)
Venezuela Comprehensive general practitioner, nurse, paid primary care Yes, user population assigned by
CHW
‘Barrio Adentro’ teams
–
–
1250 users or 250–350 families
per team
Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).
Intersectoral collaboration to address social determinants and
promote health is another core component of comprehensive PHC.
All countries’ PHC policies specify health promotion, conceived as
action on social determinants and/or lifestyle changes, to be a key
component (Table 1). Argentina, Chile, Colombia, Ecuador and
Peru provide for nationwide intersectoral bodies. Bolivia, Brazil and
Uruguay have national programmes, while Guyana, Paraguay and
Venezuela have regional or local indicatives. At the territory level,
in all countries, PHC teams take initiative to coordinate local intersectoral actions, with strong variations between countries (Table 3).
Bolivia, Ecuador and Venezuela are conspicuous for strongly intersectoral approaches to deploying public policy on the ‘living well’
paradigm. These involve integrated sets of social development policies in which different sectors converge. Several actions have been
undertaken with potential positive impacts on the social determinants of health.
With the exception of Suriname and Argentina, in all South
American countries, social participation in health is formally institutionalized through national and local health councils (Table 3). The
community action of PHC teams is generally intended to mobilize
social participation for specific actions and empower the population
to pressure governments to ensure public policies such as garbage
collection, sanitation and access to clean water. In most countries,
the initiatives are sparse.
In terms of outputs and outcomes, the effect on population
health of the various PHC systems is difficult to assess because of
the variety of starting points and the myriad of confounding factors, such as economic and social determinants of health. This is a
limitation of this qualitative research that should be resolved with a
quantitative study. All countries show improvements in the mortality rate of infants and children under five, which could be related to
the poverty reduction since 2000 in the region (19). Nonetheless, in
a 2000–12 comparison, countries with renewed models of PHC that
focus on comprehensive, family and community care, such as Brazil,
Bolivia, Ecuador and Peru, seem to have better gains (Table 4). Chile
and Uruguay have the best results in both years.
Discussion and conclusions
Today PHC is being revitalized in a diversity of processes that are
underway in SA involving new models of family, community and
intercultural care. New policies and renewed models of PHC are
being implemented in seven countries (Bolivia, Brazil, Chile, Ecuador,
Paraguay, Peru and Venezuela) that include a common mention of
Mapping primary health care renewal
265
Table 3. Intersectoral cooperation and social participation in primary health care in South American countries
Countries
Arrangements to develop intersectoral cooperation
Social participation
Argentina
Intersectoral initiatives occur on the National Social Policy Coordination
Council, the Inter-Ministry Mental Health Program and the Community
Health Facilitator Training Program. In the municipalities, these converge in
the Community Integration Centres, involving actions by the Ministries of
Health, Social Development, Labour and Planning and the Social Cabinet.
Locally, the PHC teams pursue intersectoral actions through the ‘Abordaje
Territorial’ and ‘Cuidarse en Salud’ programs.
The main intersectoral policy is the Zero Malnutrition Multi-Sector Program
(involving 11 ministries, state and municipal governments and NGOs). At the
local level, primary health teams relate with other sectors for specific activities in education, urban cleansing and so on.
One of the main intersectoral social development policies is the ‘Programa
Bolsa Familia’, which transfers income to poor families, with conditionalities including health actions with the support of family health teams. In the
territory, these teams must mediate intersectoral actions to address the social
determinants of health.
Intersectoral Action for Health (IAH), in place at all levels, is coordinated by
the Ministry of Health and local governments. PHC health teams work with
IAH by pursuing social protection programs and through the ‘Vida Chile’
committees, which implement promotion policies with health team and community participation.
A number of intersectoral committees have been set up at the national level,
among them the National Intersectoral Committee on Public Health, to guide
interventions on the social determinants of health. Territory-level
intersectoral coordination and participation PHC teams is limited to a few
municipal ventures.
At the national level, the Ministry of Social Development is tasked with
connecting the ministries of Sport, Housing, Education, Environment, Human
Mobility and Health to introduce intersectoral programs in the administrative
zones. At the local level, PHC teams interrelate with other sectors for specific
outreach activities, mainly in schools.
Intersectoral collaboration is facilitated through the ‘Consejo Democrático
Regional’, which is a government administrative body responsible for social
services in the regions.
At the territory level, Family Health Units coordinate their actions with state
and municipal governments and community organizations, such as NGOs,
Neighbourhood Committees and Local Health Councils. PHC team interaction with community organizations and NGOs in the territory depends on
the self-management of each Family Health Unit.
At the national level, the General Directorate for Health Promotion sets out
action plans and joint work pathways among sectors. The Integrated PHC
Networks involve participation by the Health and Education Secretariat,
Ministry of Housing and the community sector, forming an intersectoral
committee that sets up a territorial health plan and health promotion actions.
At the local level, PHC teams conduct health diagnosis by geographical
sector, set up family and community care plans and sign communal commitments to involve the local population and galvanize intersectoral actions.
At the district and community level, Public Health Secretariats, Regional
Health Services and the Medical Mission engage in intersectoral initiatives.
The Public Health Secretariat collaborates with other sectors, especially in
environmental health, with the participation of local organizations.
One of the key experiences in national intersectoral policy is ‘Uruguay Crece
Contigo’, which fosters interventions focused on zones of extreme poverty,
coordinated by the Planning and Budget Office of the Presidency of the
Republic, with the Ministry of Health and other ministries. In the territory,
intersectoral collaboration is based on this policy, combined with actions
suited to local situations, and interacting with formal or informal State or
community organizations with a territorial presence.
The ‘Barrio Adentro’ mission is conceived to be a space integrating all social
sectors under the principle of ‘buen vivir’ (‘living well’). Health teams have a
permanent relationship with the education sector and form part of comprehensive local development initiatives, e.g. by ‘Barrio Nuevo’ programs, which
address local problems with participation by all social development sectors.
Informal arrangements: local councils; in the territory,
they coordinate with community organizations, social
clubs and non-governmental organizations (NGOs)
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Formal arrangements: committees and councils at the
national, state, municipal and local levels
Formal arrangements: Health Councils at the national,
state, municipal and local levels
Formal arrangements: Local Health Councils and Local
Development Centres in each municipality
Formal arrangements: Community Participation Committees, Local Social Planning Councils, Local Health
Councils, hospital boards
Formal arrangements: Local Health Committee in PHC
facilities, Civic Health Sector Council
Formal arrangements: Neighbourhood Councils and
Village Councils.
Participation institutionalized in the Constitution
Formal arrangements: Local Health Councils and Subcouncils
Formal arrangements: Communal Surveillance Systems,
Local Development Committees
No formal arrangements for social participation
Formal arrangements: National Board of Health,
Advisory Councils, State Boards of Health. Informal
arrangements: neighbourhood or support committees
Formal arrangements: Communal Councils and Local
Health Committees
Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).
Family Practice, 2016, Vol. 33, No. 3
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Table 4. Outcomes on population health of the primary health care systems in South American countries
Country
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Perú
Suriname
Uruguay
Venezuela
Infant mortality rate
(per 1000 births)
Mortality rate under
5 years (per 1000
births)
Maternal mortality
ratio (per 100 000 births)
% of births attended by
% of children under
trained personnel
1 year of age
immunized against measles
Year 2012
Year 2000
Year 2012
Year 2000
Year 2012
Year 2000
Year 2012
Year 2000
Year 2012
Year 2000
10.8
50
14.5
7
17.5
8.6
23.3
14.6
17
15.1
7.8
14.9
16.6
65
27.4
8.9
25.8
No data
21.9
20.2
33
20.2
14.1
19.4
13.3
39.1
16.5
8.2
16.9
22.5
36.6
21.9
16.7
22.8
11.1
14.9
20.2
77.4
32.9
10.9
25.1
34.3
48.7
33.5
39.8
34.8
16.8
21.3
32.5
229
61.6
15.7
65.9
45.7
No data
96.3
93
82.5
18.6
69.8
35
230
89.7
18.7
104.9
No data
133
164
185
No data
No data
60.1
95
86
100
97
91
70
98
73
89
85
96
89
95
100
100
97
80
84
86
92
97
71
89
84
99.7
73.5
99.1
99.8
98.6
94.7
98.3
96.8
91.4
90
99.9
99.5
97.9
60.8
96.7
99.8
93.5
No data
90.3
No data
59.3
90.6
No data
No data
Source: PAHO (26).
comprehensive care, family focus and community focus with social
participation. Implementation is gradual, however, and many of the
policies have not yet fully achieved their expected results, as found
in some prior studies (20–23).
Tensions that remain as conceptions of PHC differ among and
within the countries, and the focus of implementation varies from
selective, focalized packages through emphasis on primary-level care
integrated into the care network, to experiences of strong community action, intercultural approaches and impact on social inequalities, with PHC integrated into a social development policy (as in the
‘living well’ paradigm).
Emerging empirical categories analysis show that the process of PHC implementation can be seen to involve common elements relating to the existing modality of health systems and the
related segmentation of coverage. Prevailing assurance framework
rules stipulate separation and specialization of stewardship, funding, insurance and service provision functions, and the inclusion
of multiple public and private agents. The public subcomponent
of such systems on which PHC depends is generally designed to
protect the population with no means of payment and the lowerincome working population. Although insurance fund administration models differ from country to country, the administrator
institutions are responsible for risk management, financial resource
management, user access and service provision procurement. These
characteristics of the health systems mean that, although national
governments respond formally for the approach to PHC design and
implementation (which are based on renewed PHC), the power of
the public or private institutions responsible for insurance funds is
decisive when it comes to defining PHC approach, funding organization and operating mode.
In this manner, two trends can be seen in how PHC models are
organized. One is associated with segmented health systems characterized by individual risk-focused insurance, a market orientation
and separation into individual benefit packages and collective interventions, involving different sets of teams, one for individual care
and another for collective and community actions. The other model
is associated with health systems where the public sector and territorialized state planning predominate, and where individual care and
collective and community interventions are coordinated under the
responsibility of the same health team.
Implementation of a comprehensive PHC approach encounters
the same obstacles as efforts to build universal health systems in SA
(24,25). It is conditioned and influenced by the prevailing modality of social protection in health. In countries where coverage is
segmented into private or public insurance, with service packages
differentiated by users’ ability to pay, the PHC approach comprises
packages centred on first-level individual care, with no territorial or
collective dimensions. In cases of subsidized insurance focalized on
low-income populations (or mothers and children or older adults),
the PHC focus is selective and based on a minimum service package.
This approach could be termed neo-selective PHC.
In countries seeking to build universal public health systems to
meet individual and collective needs regardless of ability to pay, PHC
being implemented is closer to the comprehensive approach proposed
at Alma-Ata. There, PHC is a strategy for coordinating health care by
ordering a comprehensive service network with social participation
and intersectoral action to address social determinants and promote
health, inseparably from national economic and social development.
The multilateral agencies’ PHC renewal proposals advocate PHC
as a strategy for reorienting health systems. However, this process is
conditioned by health system funding and organizational arrangements. The segmentation of coverage and funding and the fragmentation of care, which have worsened over recent decades, hinder
the implementation of comprehensive PHC, even in the context of
comprehensive care policy proposals. There is a need for the two
main existing models to be studied comparatively to evaluate their
impacts on health outcomes and on equity in health.
Declaration
Funding: South American Institute of Government in Health (ISAGS).
Resolution 06/2012 of the Health Council of UNASUR
Ethical approval: followed the ethical principles of the Declaration of Helsinki
and adhered to the Belmont Report principles, and obtained informed consent
from participants.
Conflict of interest: none.
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