In his paper, Humberto Fonseca reports the reforming concern that has been undertaken “in what has been called the Health Sector Reform of the Government of the Federal District (DF) in the period 2015-2018.”
In 2015, the Federal District underwent a reform of its health system, aiming to establish a regionalized health care network, organized from primary care and based on the Family Health Strategy. These reforming processes seem to be a priority in several South American countries11. Acosta Ramírez N, Giovanella L, Vega Romero R, Tejerina Silva H, Almeida PF, Ríos G, Goede H, Oliveira S. Mapping primary health care renewal in South America. Fam Pract 2016; 33(3):261-267.. Some countries are implementing a reform with coverage segmented by public and private schemes, and some other, with a predominantly public sector with individual, family and community care are coordinated by the same team.
What is happening, in this case, is the application of a model whose common feature is the expanded concept of PHC, with territory-based family and community components, a multidisciplinary team, the incorporation of community health workers and social participation22. Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saude Publica 2017; 33(Supl. 2):e00118816.. The implementation process highlights the insufficient supply of physicians and the difficulty of their provision and fixation in peripheral areas, issues of poor relationships and lack of careers. Initiatives to direct the workforce to the public system, namely public examination for family doctors with a specialist title, attracted doctors from other areas of the country to Brasília. An effort to expand PHC in the DF with examined health professionals, which is noted and welcomed, is ongoing.
Several PHC revitalization processes are underway. Their implementation is progressive, and the expected results have not yet been fully achieved. However, “one must be prepared to take advantage of the windows of political opportunity”33. Soranz D, Pisco L. Reforma dos cuidados primários em saúde na cidade de Lisboa e Rio de Janeiro: contexto, estratégias, resultados, aprendizagem, desafios. Cien Saude Colet 2017; 22(3):679-686. that are unrepeatably set to carry forward the reform processes.
Even in the best consolidated public systems, reforms are heavily reliant on the rapid changes in economic power that have acted as a brake, not so much on planning but, above all, on implementation processes. This has resulted in the segmented and incomplete proliferation of somewhat unstable models that, not breaking with preceding ones, end up with the coexistence of old and current work processes and management models that increase users’ mistrust and difficulty.
Humberto Fonseca describes a reform process that has closely followed the trend in several Latin American countries since 2000. The results are still inconclusive, marked by times of economic and social crisis in Brazil. Faced with the constraints caused by the reduced role of the state, health reforms face problems related to financing, system management, institutionality of public policies, correlation of internal forces of the dominant political groups and the opinion of the technical-scientific community before power structures.
We salute all the effort and commitment that the author and his team have placed in the ongoing reform process, we sympathize with the social movements that are reforming health and we support the action of those who try to organize care with proximity and quality for all.
- 1Acosta Ramírez N, Giovanella L, Vega Romero R, Tejerina Silva H, Almeida PF, Ríos G, Goede H, Oliveira S. Mapping primary health care renewal in South America. Fam Pract 2016; 33(3):261-267.
- 2Giovanella L, Almeida PF. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cad Saude Publica 2017; 33(Supl. 2):e00118816.
- 3Soranz D, Pisco L. Reforma dos cuidados primários em saúde na cidade de Lisboa e Rio de Janeiro: contexto, estratégias, resultados, aprendizagem, desafios. Cien Saude Colet 2017; 22(3):679-686.