40 years on. Has the vision of Alma-Ata been realized?
Cadernos de Saúde Pública
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. 40 years on. Has the vision of Alma-Ata been realized? 40 anos depois. A visão de Alma-Ata foi concretizada? Después de 40 años. ¿Se ha hecho realidad la visión de Alma-Ata?