Primary Health Care-Myth or Reality E-Book

Herminio Raúl Rojo

• Herausgeber: Editorial Autores de Argentina
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 311

Veröffentlichungsjahr: 2025

Beschreibung

With Primary Health Care: Myth or Reality, Drs. Rojo examine the influential international role that the Alma-Ata strategy has assumed. It remains a determining factor for nations, and despite the passage of time, continues to be a key component in delivering healthcare services to their populations. The chapters, diverse in content, offer both descriptions and opinions, providing the reader with valuable information. This allows them to take on the role of an independent observer and develop a critical perspective—an essential skill for shaping and refining their understanding in response to social demands.

Leseprobe

HERMINIO RAÚL ROJO EMILIANO LUCAS ROJO

COLLABORATORS

RAFAEL LUIS LAPERCHIA CARLOS ALBERTO LEIVA GUILLERMINA MERCEDES ROJO PILAR ECHAVE MARÍA EMILIA CERMIGNANI PAULA SOSA

Primary Health Care-Myth or Reality

Second Edition

Rojo, Herminio Raúl Primary Health Care-Myth or Reality : Second Edition / Herminio Raúl Rojo ; Emiliano Lucas Rojo ; Contribuciones de Rafael Luis Laperchia ... [et al.]. - 2a ed - Ciudad Autónoma de Buenos Aires : Autores de Argentina, 2025.

Libro digital, EPUB

Archivo Digital: descarga y online

ISBN 978-987-87-6048-3

1. Medicina. I. Laperchia, Rafael Luis, colab. II. Título. CDD 610

EDITORIAL AUTORES DE [e-mail]

Tabla de contenido

Dedication

Acknowledgments

Glossary

Authors’ Prologue

Chapter I - Introduction

Chapter II - Primary Health Care

Chapter III - Legal Regulatory Framework of PHC in Argentina

Chapter IV - National Comparative Analysis of PHC

Chapter V - PHC in the City of Buenos Aires

Chapter VI - PHC and Immediate Care Units in the Province of Buenos Aires

Chapter VII - Networks and Nodes

Chapter VIII - The German Healthcare System

Chapter IX - The Canadian Healthcare System

Chapter X - PHC and AHC in a Social System of 114,978 Beneficiaries

Chapter XI - Implementation of PHC during the COVID-19 Pandemic

Chapter XII - Results of the PHC Strategy during the COVID-19 Pandemic

Chapter XIII - Public Health in Latin America

Chapter XIV - Spirit of a Law on PHC and AHC

Chapter XV - Management of the complete Health System. PAH y AMA.

Epilogue

Appendix I. Current Status of Healthcare in Argentina

Appendix II. PHC Bill

Appendix III. Pandemic General Regulations by Carlos Leiva

References

Dedication

To my partner, my beloved Elbita; we were always more than two.

To my beloved children.

To my dear parents.

And to two beings of light and infinite love, doña Amalia and abuelita María.

The author

Acknowledgments

Now all that a son of the plains may do,

To none shall I give best;

And none may daunt with a windy vaunt,

Or bristle my scalp with a phantom gaunt,

And as song is free to all that will,

I will sing among the rest

Martín Fierro

I was born into a working-class family that for 36 years rented an apartment: a three-room place with a small patio in Nueva Pompeya, a proletarian neighborhood in the south of the City of Buenos Aires. After much struggle, and not without hardships, they finally owned their own home. They raised me calmly, with all the love they could give me, and showed me a path.

My instruction was “completed” in public schools and the respected University of Buenos Aires. My parents and the State shaped my education and part of my soul, but there is someone, small in stature, sweet, with a very kind gaze, passionate, with convictions and roots very similar to mine, who molded my formation, leaving me as I am today: a complete being. She is my everything, she made me a man with love and soul. I can’t conceive of myself any other way. All my affection belongs to her, and I hope to continue cherishing the game of love that makes life together a true joy.

I dedicate this work and the legacy of an imperfect father and an imperfect creation to my beloved children. Their mother and I both live in and for them. To the youngest, Lucas, my collaborator and contributor to parts of this book; to the intelligent, beautiful, and dazzling Paula; and to the two eldest, Alejo, the perplexing yet tender, thoughtful, and musical soul; and finally, to the sensitive and loving Mariano. I am forever grateful for everything they have taught me, and I hope that what I have accomplished may serve them in some way.

I am deeply thankful to Doña Amalia, my mother-in-law, a being as beloved as she is essential in our lives, always ready to help with everything.

I want to thank my treasured mentors and colleagues from my professional journey: Drs. Hugo Borré, Alfredo Lanari, Luis M. de la Fuente, and René G. Favaloro. I am profoundly thankful for all the life lessons taught and the kindness they always showed me. To my friend and mentor Dr. Guillermo Semeniuk, his clinical wisdom, and exemplary conduct I dedicate this structure and system.

I must acknowledge accountant Dr. José Luis Delfino as the great creator of real dreams. He was instrumental in both shared and personal projects, as well as the profound and robust transformation of the health system we achieved. He was my life partner, and to him I dedicate my deepest and most cherished feelings.

Finally, a special and deep gratitude to Mr. Oscar Guillermo Rojas, President of the Maintenance Workers’ Union Health Insurance, who enabled us to create a very unique health system, focusing on Primary Health Care (PHC) and Ambulatory Health Care (AHC). I am especially grateful to him, who taught me so much, almost without words, as we shared our experiences—so different yet so similar—building from rubble-filled clinics to the robust social health system it is today. To him, I extend all my recognition.

I must thank my secretaries, Mariana Marsilli and Vanesa Frutos, for their unwavering willingness and constant support. Their essential work sustains our daily efforts and makes better healthcare possible.

I went to bed in Villa Fiorito having a mortadella sandwich,

and I woke up in Paris drinking champagne.

Nobody prepared me for that.

Diego A. Maradona

Glossary

PHC. Primary Health Care.

AHC. Ambulatory Health Care.

WHO. World Health Organization.

PAHO. Pan American Health Organization.

Equity. Equal distribution of resources and actions in healthcare.

Free access or access. Non-discriminatory access to humans’ right to health.

Accessibility. The ability of a population to receive healthcare services.

Effective access. The ability to meet a person’s or system’s needs.

Progressive care. A resolution strategy organized into subsystems and systems.

Regulation. Articulation of networks or systems. Its synonym in management is articulation, though articulation has a broader meaning than in its mathematical sense.

Modulation. A series of essential functions that involve establishing, implementing, and monitoring the game rules for the healthcare system, providing it with strategic direction.

Articulation. According to Chernichovsky (154), it refers to the organization and management of healthcare consumption. This function includes demand aggregation and consumer representation roles assigned to sponsors in managed competition models (155, 156). This function lies at the intersection of financing and service provision.

Integration. It refers to the connection between each of the essential components of the population and the institutions within a health system. It is the degree to which different population groups have access to the health system’s institutions.

  a. Horizontal integration. It refers to how population groups access the same institutions. Many authors use this term as a synonym for consolidation. In Argentina, the term applies more to demand (population) than to supply (institution).

  b. Vertical integration. It refers to how one institution or node has different functions and access points.

Integration describes the typology of the main health system models prevalent in Latin America.

Comprehensiveness. It focuses on solving health problems by organizing the system.

Fragmentation. Coexistence of many units or entities not integrated into the health services network. It is caused by regulatory frameworks.

Segmentation. Division of population groups with varying health coverage due to economic reasons or inefficient and ineffective medical-administrative health paths.

Atomization or particularization. It refers to the patient that collides with pent-up demand and is excluded by the system. The terms atomization and particularization were borrowed from quantum physics. This etymological basis was used metaphorically to describe poor healthcare management.

Systematic. Analysis of each element within a coherent framework.

Systemic. Analysis of the health system in its entirety and in relation to each of its parts.

Service portfolio. Set of health actions defined by the network.

PCC. Primary Care Center.

Immediate care unit. Similar to Primary Care Centers.

Fever clinic. Non-hospital units where temperature and symptoms are recorded to determine whether a case is suspected of COVID-19.

Health care and community action center. Similar to Primary Care Centers and immediate care units.

Reference Center for Ambulatory Medical Specialties. Facilities focused on diagnostic imaging, laboratory testing, and other specialized medical services.

Resolution capacity. The capacity of a health facility or the response capability of a health system.

Counter-referral. Care transition from a specialist back to the primary care physician for continued patient follow-up.

Co-responsibility. Responsible collaboration to foster a sense of belonging.

Coverage. The health action response provided by a specific management system. For example, coverage by public health services, a social health insurance scheme, or a private system.

Demand. The number of services socially and technically required by a population.

Efficiency. The use of appropriate resources to produce health services, avoiding waste and excess.

Effectiveness. The ability to achieve expected results within a specified timeframe.

Strategy. A plan with defined goals.

Tactic. Each individual goal of a strategy.

Vision. The envisioned outcome or future state of the system.

Mission. The composition of each subsystem, reflecting a partial approach.

Flexibility. The ability to apply a model across different options.

Management. The proper use of human, technological, organizational, and financial resources.

Jurisdiction. The territorial level for the management of systems and their networks.

Macro-networks. Healthcare networks that go beyond the boundaries of a jurisdiction, node, or provincial or national region. Nodes.

Comprehensive care model. A system where resources are organized into levels of care.

Management Model. The method by which financing and care are integrated.

Supply. Human and physical resources available, translated into services.

Primordial prevention. A set of actions aimed at preventing the emergence and consolidation of social, cultural, and environmental patterns that increase the risk of disease.

Primary prevention. Actions that reduce the incidence of diseases by controlling risk factors.

Secondary prevention. Health actions aimed at shortening the duration of illness.

Tertiary prevention. Actions aimed at reducing the progression and complications of an established disease.

Network. Set of interrelated health facilities or services.

Node.

  a. Institutions providing low, medium, or high complexity ambulatory care.

  b. Articulation point of various networks with the Primary Care Center (authors’ note). A PCC can coordinate multiple independent or interrelated nodes.

Actor. Organization as part of a network of organizations.

Process. Interorganizational integration occurs, involving resource exchanges, driven by agreements and connections between organizations.

Components of networks. Nodes, internodal relationships or links, exchanges, the central action of social support, and health policy.

Universality. The expansion of access, coverage, and services offered with equity.

SNF. Skilled Nursing Facilities. Systems providing home hospitalization and specialized nursing care.

IDT. Interdisciplinary team specializing in oncology, chronic ambulatory dialysis, mental health, neurology, traumatology/physiotherapy, and similar areas.

IHSN. Integrated health service networks encompassing clinical analysis laboratories, diagnostic imaging, and pharmacies offering both high- and low-cost medications.

Day hospital. Facilities for short-term hospitalization, including day hospitals for low- to medium-complexity ambulatory surgeries and high-complexity day hospitals with 24- to 72-hour hospitalization.

Authors’ Prologue

The purpose of this book is to analyze the current state of the implementation of the Primary Health Care (PHC) strategy, agreed upon by the nations at the International Conference on Primary Health Care in Alma-Ata in 1978, convened by the World Health Organization (WHO). The aim is to address the controversy surrounding the universality of the 1978 WHO Declaration, which persists to this day.

There is concern arising from the perception that time elapsed since the Alma-Ata Conference, along with global transformations, must be considered when evaluating the strength of the commitment.

Is PHC a low-complexity attention module? Is it the gateway to the medical care services system? According to the original definition, both are true as they were established in pursuing an integrative outcome that brings together all components working to address health issues and their determinants.

Is PHC a primitive system? Is it a rudimentary gateway to health with no clear outcome? What were the impacts on health following the Alma-Ata Conference? Were health resources optimized? These and many other questions should have been answered over time, but new questions have arisen shaping the health care system and the perspectives of individuals.

What specific benefits have been obtained over the 40 years of existence of the PHC strategy? Did they really exist as such? In an objective analysis, PHC improved all key health indicators, as stated by the WHO:

• The infant mortality rate was reduced by one-third.

• All causes of mortality decreased by 25%.

• Life expectancy at birth (LBE) increased by an average of 15 years for the global population.

• Deaths from infectious and cardiovascular diseases fell by 25%.

• Perinatal mortality decreased by 35%.

• Maternal mortality also decreased significantly.

The fact that more than 40 years have passed means that a more precise assessment can now be made. A simple recounting of historical events would suffice to demonstrate the success of this system, which disruptively challenges the outdated, fragmented healthcare structure, and highlights the hospital bed as the passive and static place where the delay in diagnosis hinders the timely application of therapy.

In Argentina, a snapshot of the current healthcare model would reveal a map as heterogeneous as it is real, with areas of inequality and genuine limitations in access to the right to health, where “primitive care” remains the norm. Currently, the existing PHC system remains underdeveloped, with highly fragmented networks, offering only partial responses in the national and provincial sectors.

In fact, the needs of most of the population are fulfilled by PHC—82% of older people and 93% of younger age groups—, while the needs of the rest of the population are met at the secondary and tertiary levels of care.

As we will see, the concept and development of PHC are broad, complex, and universal. It induces a continuous updating of systems and subsystems, where geographical and ethnic factors characterize each area.

It would be appropriate to define here the fragmentation of health services. According to the Pan American Health Organization (PAHO) and the WHO (2007), it refers to “the coexistence of units or facilities that are not integrated into the health network.” In practice, it can be seen in the structural difficulty to access health services. This reality holds the 101 laws, decrees, and resolutions enacted responsible for creating structural failures of varying complexity and determining national fragments as provincial and social.

The segmentation of the health system is related to the fact that different population groups have different coverage depending on economic or work differences. It is obvious that whoever articulates and leads the PHC better, will achieve better health care for everyone.

We will also explore how a health system operates, with particular emphasis on primary-level ambulatory care (PHC and AHC), during a global emergency such as a pandemic. The book will examine the actions taken, the management, the structures involved, the planning carried out by the subsystems, and the results, which are still partial at this stage.

As this is not a specific study on the ongoing pandemic, the second level of care (hospitalization) will be documented, but it will not be the primary focus. What is of special interest, however, is the health system, the management and action protocols, as well as the coordination in the face of existing fragmentations and segmentations.

Hopefully, in the development of this short book, answers will be provided to all the questions that we have asked ourselves, based on the actions and articulations that we carried out and the results that we obtained. Despite adversity, we managed to plan, program, protocolize, manage, and articulate challenging tasks. Chapter after chapter, we have built the complex operation of all the tools of the PHC system and the AHC taken to their maximum expression.

An old Spanish Republican anecdote tells that in the middle of a final battle in the trenches of Madrid, an acolyte soldier asked the character: “Generalisimo! How can they not be defeated?” The answer was laconic, immediate, and simple: “Because there are Spaniards on the other side too, hombre!” This is what happens in Argentina, where legislation—laws, decrees, and resolutions—fragmented public health and initiated the segmentation of entities, groups, and subgroups, including ethnic groups, and ended with the phase of particularization. Health care collapsed due to unmet demand; however, in the pandemic, a progressive ordering of response was accomplished.

What explanation can be provided for the fact that, in times of social degradation and the pandemic, our public health care system was not defeated? Heroic actions in public health were seen in primary health care centers, febrile units and referral systems, and isolation of areas, social groups, families, and hotels. These are all PHC and AHC elements and tools.

The answer to the question is as laconic as in the Republican anecdote: On the other side of the coronavirus pandemic, there are Argentine doctors, nurses, technicians, researchers, and legislators… and, as if that was not enough, there’s the Malbrán Institute, the National Scientific and Technical Research Council (CONICET) and the new universities of the Metropolitan Area of Buenos Aires developing medicines, a hyperimmune serum, and even antifungal, antibacterial, and antiviral masks. All these institutions were cradled by the persistent thought of their creators: Professor Doctor Alfredo Lanari, René Gerónimo Favaloro, Luis Mansueto de la Fuente, Bernardo Houssay, Luis Federico Leloir, and César Milstein, among others.

Glory and praise to them all.

Mankind is composed of two sorts of men:

those who love and create,

and those who hate and destroy.

José Martí

Chapter I

Introduction

The first lesson taught in the admission course at the University of Buenos Aires was a mnemonic regarding taxonomic classification, which went as follows: “Dear King Phillip Came Over For Good Soup” (domain, kingdom, phylum, class, order, family, genus, species).

The domain refers to the conservation of genetic material in either a constant or variable manner. In other words, members maintain the same number of chromosomes during reproduction, resulting in the formation of two eukaryotic beings (eu, “same”; karyos, “genetic material, chromosomes”). While humans and plants share this domain due to having the same number of chromosomes, they differ significantly across kingdoms.

Chart 1. Examples of taxonomic classification

Human being

Sunflower

Domain

Kingdom

Phylum

Class

Order

Family

Genus

Species

Eukarya

Animalia

Chordata

Mammalia

Primate

Hominidae

Homo

sapiens

Eukarya

Plantae

Anthophyta

Dicotyledoneae

Asterales

Asteraceae

Helianthus

annus

The main historical concern is with the classification of the three realms in nature: animals, plants, and minerals. It is clear that man is an animal, and that all animals have self-awareness or individual consciousness. It is beyond the scope of this book to discuss whether plants and minerals have it or not.

Sardines are small fish whose first or last way of defending is to travel the seas in schools. In the school, each animal senses those nearby, forming a perfect octahedron, which functions as a virtually unalterable and associated unit. Each being senses a distance of 1.5 to 3.2 centimeters from the others and maintains it under all circumstances, except when the school is attacked by a shark or, on occasion, a whale. This phenomenon is called collective consciousness and the reason for its existence is simple: to suffer less damage. The predator, even if it is a mammal, passes through the school, scattering it with little pain and even less glory, catching very few sardines.

When it comes to whales, the situation is very different. These mammals also possess collective consciousness as a mechanism for association, and they demonstrate it whenever they encounter schools of fish by acting in unison. A group of whales dives and stays at the bottom, forming a circle around the school of sardines and they begin to release bubbles that rise to the surface. Once the school is enclosed, two or three cetaceans, depending on the size of the school, attack from the bottom towards the surface with their mouths open, feeding as they alternate their roles, some producing bubbles while others attack.

There is both individual and collective consciousness in various types (phylum) of animals, becoming more refined the closer they are to mammals (class). When we observe primates (order), other defining characteristics stand out: They live in families, they have some organization regarding the tasks the community must fulfill, and they slowly and with difficulty develop simple tools. Another trait is their voice, kind of guttural sounds. This feature can also be observed in cetaceans, which make both low and high-pitched sounds, and use them as alarms or as calls in their songs.

The Hominidae family encompasses all the previously mentioned characteristics, which have been practically forgotten since Linnaeus and Darwin. An interesting historical fact about these two figures is that they met when one was entering old age and the other was leaving youth behind.

Leaving aside these causes (taxonomy and Darwinism) in the family of the genus Homo and the species sapiens—where perfection is nearly absolute for this terrestrial order and where carbon, nitrogen, and oxygen chemistry reign—, the emergence of voices, activities, labor, and developments began. One of these developments concerns the methods of addressing health issues.

From a philosophical perspective, the Hominidae family, subject to social determinants, strives for perfection in the health of its members and applies individual and collective consciousness by providing PHC and AHC.

Since not everything tends toward perfection, attempts were made to regulate this development, but not all of them did so coherently; as you will learn throughout these pages: inconsistencies, even within a country, are evident. Regulations respond to interests that are difficult to discern, leading to segmented “social determinants” that stem from the very rules themselves.

Rational concepts aimed at achieving urgent results apply theories where the objective is specific rather than general; indicators are improved as mission rather than vision. This temporary change causes health care to become a threat to health itself. If there is any doubt about this, let us analyze the pandemic.

The global action of the WHO and the PAHO during the pandemic presents a scenario where competing interests eventually converged—curiously, coincidentally, or causally—through organized and planned social isolation. In this context, PHC played a direct role, becoming a guiding voice that led to an organized health effort across different types of isolation: at home, in specialized hotel institutions, and in healthcare facilities.

In this book, an attempt is made to highlight the historical changes that have occurred in the health sphere, which led to the organization of public health in Argentina, with an emphasis on social security. In the following chapters, the concept of PHC is defined, and its evolution over time and the complexity it has acquired globally are discussed. Argentine regulations, along with regional, provincial, and municipal regulatory attempts —formulated under complex social determinants—are herein addressed.

Since the origin of the PHC Law and its regulations, there has been a persistent, albeit partial and fragmented, interest in the creation of volitional subsystems for its application. There has always been a particular interest in legislation that tends to segment regional efforts or, more realistically, tends to group different levels of unsatisfied basic needs without directly addressing them. As segments do not transform on their own, a partial solution is achieved that contributes to the atomization of health actions over time. This collides with unmet demand, which is generally hospital-related and, more often than not, social.

While maintaining the focus on PHC, Germany’s health system will be introduced into the discussion as a comparable and similar example to that of Argentina, with a health system that is desirable due to its established complexity. Canada’s health system will be studied as well.

A comparative analysis is later made of the same health needs, but in Argentina, focusing on the capital city, Greater Buenos Aires, and the province of Buenos Aires, the most populous state. The aim is to determine where the PHC system stands and where changes happen in real time. This chapter details the development of an entire system based on PHC for a large community of over 100 thousand beneficiaries, outlining the programs and, most importantly, the unexpected and unbudgeted real-time reaction of the system to the SARS-CoV-2 pandemic. We highlight the applied subsystems, the monitoring of proposed indicators, and the partial results, given that the pandemic is not yet over. The response of the PHC system and its networks to this unfortunate global event is examined.

The Latin American scene needed to be defined, and required updates continued to be included in the WHO/PAHO proposals. It is important to note, however, that these were completed by the deadline of December 2019, only to be overtaken by the onset of the pandemic, which began in October of that same year.

This book does not focus specifically on the pandemic, but it cannot overlook the responses provided and the changes undergone by our health system. This is just the beginning, and we must develop the spirit of a PHC Act and its networks.

It is not his hands only, Sophocles,

that a general must keep clean,

but his eyes as well.

Plutarco

Chapter II

Primary Health Care

It all started long ago, when human society became more complex and interests developed to the point of objectifying the obvious structural distortion. This chapter defines PHC and describes how successive experiences attempted to regulate and organize the system.

Definition: Declaration of Alma-Ata, 1978

The Declaration of Alma-Ata issued on 12 September 1978 at the International Conference on Primary Health Care, expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world (1).

The WHO/PAHO define PHC as essential health care made universally accessible to all individuals and families in the community through their full participation, and at a cost that the community and the country can afford (2). Thus, PHC addresses everything from changes in social, environmental, and community determinants to health policies to improve the quality of life (3).

The Physician in Antiquity

Throughout its evolution, healthcare models began with personal actions—whether professionalized or not—, transitioned to individual diagnosis and care, and culminated in collaborative efforts to assist treatment.

The activities of Aesculapius in the sixth century BC are described today as a reference for healthcare actions. According to tradition, Aesculapius developed a school of medicine in Epidaurus, Peloponnese, where his wife, Epione, soothed pain. Their daughter Panacea, formulated treatment plans that were later supervised or corrected by her father. Her sister Hygieia was responsible for preventive measures, isolation, and hygiene in cases of leprosy and syphilis, which were unified as one at that time. Their brother Telesphoros took care of convalescents, and Aesculapius’ other sons, Machaon and Podalirius, specialized in surgery and clinical medicine.

They were organized and served their respective roles on a mount, where patients first passed through the hygiene and rest area, where music and priestesses healed their souls and eased their pain, and later ascended until they reached Aesculapius. This structure of care is comparable to modern-day PHC.

In Argentina, rather than evolving, this system has become highly fragmented, and those fragments are further segmented themselves. Panacea, the physician, is isolated from Telesphoros, while Machaon and Podalirius argue and rarely consult each other. Clinical-surgical teams are segmented and atomized. Pain therapy has almost disappeared—Epione, where are you?

Hygieia—prevention, isolation, and hygiene—has become two or three desperately isolated and disconnected segments, running widely through the suburbs and along the banks of the Riachuelo, reaching the Río de la Plata, where she gets intoxicated, poisoned, and drowned. She is the best example of the atomization of the healthcare system.

This marks the segmentation of the physicians’ actions. The relationship between doctors and patients in primary care is lost or diluted and health care often ends there. Moreover, patients reach the primary level only when complications arise or when their condition becomes chronic, and this is almost always too little, too late.

Today, Epidaurus is fragmented, segmented into atoms. The relationship between the health professional, the first request for additional tests, the prescription of medication, and—most likely—the first intervention is broken.

It quickly becomes apparent that the primary care center (PCC) is the initial agent in a complex system that has to be supported through networks that include diagnostic centers and treatment facilities, among others.

In this brief history, PHC and the interrelations between PCCs, and the production and stock-up of medicines will be recounted. Of course, this is viewed from the perspective of social determinants to the improvement of life quality and the actions of health care providers.

Historical Evolution of the PHC Concept

Diagram 1. Evolution of PHC since its creation 40 years ago

Beyond Alma-Ata, more than four decades ago, PHC transformed health care policy by guaranteeing the universal right to health. Although having achieved broad global consensus, inequalities and the characteristics particular to each country hindered its implementation.

1. Primary Functions of PHC

Based on the acceptance of the universal knowledge of health as a social objective and contextualizing international and national agencies, the PHC strategy was introduced as an element of transformation for the existing health systems—Alma-Ata—(3-24). The WHO/PAHO put these concepts into action, which collided with the economic perspective implemented in the 1980s—Ottawa Charter—.

In the 1990s, when the basic needs basket was defined, the issue was reconceptualized. It ceased to be unique and was adapted to the needs of the poor, becoming the synonym of compensatory programs for vulnerable groups in extreme poverty. The actions of these compensatory programs were structurally focused.

Today, we continue moving in the same direction: isolated and disconnected from public systems and networks, constituting a second category in many developing countries, making PCC an instrument of a “primitive health network” (5 and 24).

Located within the health system, first-level care services are responsible for being the gateway to the system (first contact) (6). For these reasons, PHC became the first level of care to take into account patients and their context, forming the basis of and shaping the remaining levels. It conditioned the health system to ensure universal coverage and access to services fairly and acceptably. Taking individuals, families, or communities as the ground for both PHC and the established Millennium Development Goals (MDGs), the fundamental determinants of health care are addressed (7, 24, and 25) (Figure 1).

Accountability for PHC requires monitoring and continuous improvement of the health system’s performance in a transparent manner, subject to social control (9). The State is ultimately responsible for ensuring equity and quality of health care (8).

Special controls are carried out globally by WHO and UNICEF. They serve to define standards that allow the identification of degrees of human development (social determinants of health), such as those carried out by the United Nations Development Programme (UNDP) and the Economic Commission for Latin America and the Caribbean (ECLAC), among others. The four essential functions of PHC are the following:

1. First contact accessibility

2. Continuity

3. Coordination

4. Comprehensiveness

PHC has not been and still is not a priority policy for public health in Argentina, since the model of care has historically been “hospital-centered”. Although its existence has been undisputed since the beginning, its imprint refers to the spasmodic, fragmentary, or segmental effects of partial networks or more or less organized ethnic groups. Our country has placed hospitals and philanthropy at the center and this is reflected in the regulations—successive provincial decrees and few national laws—that affect the integral evolution of PHC, fragmenting and segmenting this egalitarian systematization.

Politics did not develop an interest in the systematic implementation of the idea that health is for everyone either. Thus, from Alma-Ata to the Ottawa Charter, incoherent fragments have been observed in territorial implementation. As an example, we can look at the differences between the legislation of the provinces of Córdoba and La Rioja, compared to the other provinces. Health disparities became more evident when the MDGs were established and the strong concept of health as a right was historically developed. It was a crucial concept, universal, egalitarian, and requiring urgent application, but it has historically seen inconsistent fulfillment.

Although social determinants are evidence drawn from censuses, implementation policies have always been irregular and partial. In our country, the integrity of the system as determined in Figure 1 is nowhere to be seen.

Despite the inclusion of the concept of health as a human right and its expression as such, coordination and comprehensiveness remain deeply affected. Thus, what was established in the 2018 WHO/PAHO meeting, where the Universal Health Coverage (UHC) was created in Astana—officially Nur-Sultan—(35) (Diagram 1), proved challenging to apply in South America. The reason is that this concept unfolds politically, giving rise to at least two opposite interpretations that are difficult to reconcile due to their differing nature: One focuses on the implementation of comprehensive health insurance, the UHC, and the other, relates to State equity. At this meeting, Sustainable Development Goals (SDGs) were endorsed, renewing commitment and well-being for all, based on UHC, including marginalized or vulnerable people.

The history of PHC is critical. It is full of key principles, which are exquisitely interpreted by different organizations, where global health policies, state or public, are set out in multiple countries with complex and diverse health structures. Bright ideas do not always produce perfect solutions.

2. Secondary Functions of PHC

PHC encompasses three secondary functions: family focus, community orientation, and cultural competence.

1. Family focus. It involves individual care in relation to their immediate social environment. The question we must ask ourselves is how to include single-parent and parent-less families.

2. Community orientation. It is produced by the formulation of the health care program based on knowledge of the needs in specific areas.

3. Cultural competence. It is intended to preserve the inclusiveness with which health issues must be addressed among the different social groups in the assigned population.

If we analyze the evolution of healthcare in Argentina, we can see that, since the 1960s, there has been a tendency for the system to undergo a profound transformation in terms of the role and participation of the State. Institutional fragmentation of services and segmentation among population groups—especially in terms of their ability to pay—were established, and are still present today. In short, we can observe an atomization that negatively determined the goals and targets of the PHC strategy.

If we have progressed in the field since the declaration of Alma-Ata, it has not been without resistance and obstacles, which resulted not only in vast differences between countries in terms of results but also in the failure to achieve the goal of “Health for all by the year 2000” (Diagrams 1 and 2).

The use of up-to-date, reliable, and objectively supported information provides a sustainable basis for effective interventions. It’s called acting in the face of evidence. In this sense, it is necessary to consider the variables that make it possible to prioritize decisions and consider aspects such as the quantity and quality of evidence, which arise from the available information, the consistency of studies, and cost-effectiveness estimates of actions to be taken in relation to cost/benefit—efficiency/effectiveness. Aspirin is effective and its cost is negligible. However, there is no evidence that over time it has an exquisite ratio of efficacy/effectiveness in carefully selected pathologies.

PHC currently includes health care for a human population, which occupies a territory that is related to it or not, which integrates into society regardless of the existing political system.

3. Healthcare Levels

The term health care levels refers to a staggered form of organizational structure and delivery of health services, aimed at achieving a balance in their available quantity and variety, to meet the needs and expectations of the population.

PHC is implemented in PCCs with actions involving both acute and chronic patients. Included services comprise low-complexity imaging centers and laboratories, and the day hospital, with low and high-complexity diagnosis and treatment services, such as ambulatory, endoscopic, gynecological, traumatological, and breast cancer surgeries and outpatient centers for oncology and dialysis treatments.

The concept of health care levels is based on an epidemiological analysis of health problems, taking into consideration related technological resources and the relationship between complexity and frequency.

The first level of care is not synonymous with PHC, but its performance conditions the formation and organization of the other levels. The associations of pharmaceutical laboratories integrate this level of primary care and may or may not participate simultaneously in the other levels of complexity. The limit is the second level, hospitalization.

It is in the first level where between 83% and 94% of the population meets their healthcare needs. This justifies the application of a focus policy on these health systems and subsystems. Thus, the creation of PCCs must be validated by social determinants. PCCs should be the starting point of health policy implementation. The idea of a focus policy shall be dismissed.

4. Social Determinants of Health

All social determinants are included in the following integrative description:

• Social gradient. It is related to the individual’s attachment to the factors of the social habitat where he develops. These factors influence social progress, depression, or distortion, which, in turn, affect the environment in which citizens live. Life expectancy is lower and diseases are more common in socially depressed societies. Economic and social poverty negatively affect health. Life includes several critical transition points, with emotional and material changes affecting health.

• Stress. It causes worry, anxiety, and inability to improve; it damages mental health and can cause premature death.

• Childhood