40 years on. Has the vision of Alma-Ata been realized?

Abstract

In this issue of Cadernos de Saúde Pública, four articles describe the state of primary care in Portugal 1 , Brazil 2 , Canada 3 and Chile 4 . These papers are timely in view of the 40th anniversary of the 1978 Alma-Ata Declaration 5 . This landmark declaration in the history of primary care asserted that "All governments should formulate national policies, to launch and sustain primary health care as part of a comprehensive national health system", defining universal access to primary care as "the central function and main focus of a country's health system". Against this challenge, how has healthcare in these countries fared?Portugal moved from a system entirely based on private practice to a National Health System in 1979 with increased access to care and improvements in health indicators such as infant and maternal mortality and life expectancy, which the authors describe as "dramatic". Residency programmes in primary care were created in the 1990s, with most primary care physicians working in the public sector and universal coverage for the population. Since then, primary care has become organized into autonomous teams of physicians, nurses and administrators (Family Health Units), described by the authors as a "veritable utopia" for primary care. None of these reforms were established without considerable opposition from entrenched interests, but primary care is identified as one of the stabilizing factors in Portugal, given the country's more recent economic problems.Brazil embarked on equally dramatic reforms in 1990 with the creation of a Brazilian Unified National Health System (SUS), guaranteeing universal access to care, and the creation of Family Health Teams that now cover 90% of the population. These geographically defined teams typically have a family physician and nurses with oral health teams and other disciplines in the larger ones. Community health agents form an important part of these teams, with members drawn from the local community and so particularly well placed to understand the needs of their communities and to provide appropriate health promotion advice. The country has problems to provide enough primary care physicians, and the demand on providing populations with health teams remain high. Indeed, the vision of primary care as a coordinating force is described by the authors as a "distant reality". Nevertheless, the achievement of Brazil in providing a universal model of primary care in a large country with very diverse needs is impressive. More recent problems, also experienced by many other countries, are the entry of the corporate private providers reducing the number of physicians available to work in the public sector, allied to austerity programmes implemented by the central government. A feature of the Brazilian healthcare and the model in several Scandinavian countries is the involvement of municipalities playing a strong role in the finance and delivery of healthcare. years on. Has the vision of Alma-Ata been realized?40 anos depois. A visão de Alma-Ata foi concretizada?Desp...

Yaşlılık ve Sağlıkta Eşitsizlikler

“…Temel insan hakları içinde yer alan sağlık hakkı eşitsizliklerin derinleştiği düşünülürse ne yazık ki ütopya gibi görünmektedir. Geçmişten günümüze tartışılan eşitsizlik, özellikle Alma-Ata'da ülkeler arasındaki sağlık durumunun farklı olduğu bir süreçte "Herkes için Sağlık" sloganıyla birinci basamak sağlık hizmetleri odaklı çözüm arayışı söz konusu olmuş önemli ölçüde de sağlık düzeyi göstergelerinde iyileşmeler olmuştur (Roland, 2019). Kuşkusuz buradaki başarının altında etkili bir birinci basamak sağlık hizmetinin temel sağlık hizmetlerinin kilit taşı olarak belirlenmesi ve hayata geçmesidir.…”

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond

“…The Alma-Ata declaration was adopted six years prior to the passing of the Canadian Health Act in 1984. These two important statements both consolidated the principles of portability, accessibility, universality and comprehensiveness leading to the reinforcement of a health care system in which PHC is recognized as the foundation pillar [13][14][15] . Family medicine was established in 1966 and there are currently 115 family physicians per 100,000 patients in Canada, in addition to other medical specialists and nurse practitioners who are also providing PHC.…”

“…Rural family doctors need to acquire further skills to meet the needs of their community including procedures usually restricted to specialists 16 . Despite the maturation of this country's health care system since the declaration of Alma-Ata, Canada is still facing challenges including long wait lists and accessibility issues related to areas of very low population density and influenced by additional health determinants including age, sex, level of education and immigration status 14,15 . This makes implementing recommendations of the Astana declaration an ongoing challenge.…”

Médicos, política e sistemas de saúde

“…Martin Roland comments on the articles 15 . He recognizes the advances made, but suggests immense gaps that still persist, forty years after Alma-Ata Conference, for implementing a public, universal and integral PHC in these countries.…”