FROM THE DIRECTOR
Renewing primary health care in the Americas: the Pan American Health Organization proposal for the twenty-first century
Mirta Roses Periago
Director, Pan American Sanitary Bureau, Washington, D.C., United States of America
This special issue of the Revista Panamericana de Salud Pública/ Pan American Journal of Public Health (RPSP/PAJPH), which it is my pleasure to present, is devoted to primary health care (PHC) and is part of the movement that the Pan American Health Organization (PAHO) is leading to renew PHC in the Region of the Americas. The International Conference on Primary Health Care, held in 1978 in Alma-Ata (Kazakhstan, Union of Soviet Socialist Republics), defined the PHC concept, bringing it international recognition as the principal strategy for attaining the goal of Health for All by the year 2000. This vision of PHC was stated in the principles and recommendations of the Declaration of Alma-Ata, which marked the start of a new paradigm for improving public health and providing a new platform for international health policy (1).
Since 1978, the Region's general context has changed remarkably, due not only to the changes within the countries themselves, but also to changes of a global scale that impact both the individual and society in general. There have been substantial epidemiologic, demographic, sociocultural, political, and environmental changes that have created new scenarios with their own health risks thatin addition to the existing, unresolved threatsrequire new strategies. This complex situation reaffirms the importance given to PHC in 1978.
The connections between health and economic development are indisputable, and health is recognized as being a product of sociocultural, economic, and political processes, as well as a basic human right. Moreover, good health has a positive effect on the level of education, productivity, and general well-being of a population (2). Furthermore, inequity, poverty, abuse, violence, and injustice have a negative impact on health (3). Given the clear correlation between health and development, it is imperative that any health-improvement efforts address and integrate any determinants that exist beyond what is strictly health-related. Since PHC already approaches the individual and the family as a whole, and takes into account surrounding circumstances, PHC is the ideal strategy for taking action within the complex process that provides and protects individual and community health. The call of PHC to partner with other sectors in evaluating the determinants of health and illness clears the way for formulating public policy that is conducive to integrated, sustainable human development.
Although the Region, in general, has made considerable strides in improving various health indicators in recent decades, inequities and differences still exist among countries as well as among population groups within each country. The Millennium Development Goals, adopted in 2000 by 189 countries (5), constitute a set of measurable objectives and goals aimed at addressing poverty, hunger, disease, illiteracy, the environment, and gender equality. The means necessary for attaining these objectives and goals by 2015 complement and mutually strengthen PHC strategies. Furthermore, PHC is the ideal framework for executing the strategies already in progress toward the Millennium Development Goals, given that they are based on the same principles and valuesequality, solidarity, and social justiceand both encourage community involvement and rely on the ethical use of science and technology to harness the benefits of human progress.
The contribution of PHC to improvements in public healthdue to better access, a focus on prevention, and more skilled staffhas been widely recognized by the international community (6).1 In recent decades, a wide range of PHC experiences have been "harvested," incorporating preventative measures and improvements in education, sanitation, and access to health care services. All of these factors have made it possible to improve the Region's health indicators and social development (711).
Since the beginning of the new century, PAHO has convened meetings and developed international agreements in order to emphasize the need for reorienting systems and services in response to the demands of the new Regional context. Among the highlights have been: the Regional Workshop on Primary Health Care, held in Brasilia, Brazil, in 2001; the Declaration of Brasilia (5), in 2003; the meeting of the Working Group on Primary Health Care, held in Washington, D.C., United States of America, in 2003; the Declaration of Boca Chica, Dominican Republic, in 2004 (12); and the meeting of the Working Group on Primary Health Care, held in San José, Costa Rica, in 2004. In 2003, coinciding with the 25th anniversary of the Alma-Ata conference, PAHO initiated a project to strengthen PHC among its Member States. An outcome of Resolution CD44.R6, approved by the 44th PAHO Directing Council in September 2003, the Working Group on Primary Health Care was formed in May 2004 to promote reorienting the Region's health systems and services according to the Alma-Ata principles. The group created a key position paper based on scientific data culled from a systematic review of the literature and an exhaustive evaluation by experts within and beyond the Region (13). During the Regional Consultation on PHC Renewal in the Americas, held in Montevideo, Uruguay, in July 2005, a Regional Declaration on New Orientations for Primary Health Care was prepared, and it was ratified by the 46th Directing Council of PAHO in September of the same year.
Currently, PHC has regained visibility the world over: Governmental organizations, public and private entities, international agencies, and academia, among others, acknowledge that strengthening public health systems is fundamental to ensuring economic growth, promoting equity, and improving health.
The PAHO proposal entails a vital renewal of health systems, with PHC as the principal source of health care and services. This transformation must be designed according to the population's needs and each country's unique traits, while empowering the health systems and services with technologies designed to address most of the community's health challenges.
This special issue of the RPSP/PAJPH features two distinct and complementary parts. The first presents the PAHO perspective on the role that PHC should play as strategy for improving equity and development, as reflected in the Regional Declaration on Primary Health Care. The second part of the issue is a collection of articles that portray the wide range of PHC applications and developments in the Region of the Americas. Both sections will undoubtedly contribute to giving the reader a broader understanding of the multiple facets of PHC.
The political and moral legacy of Alma-Ata, the lessons learned, and the best practices acquired over the course of 30 years will be invaluable to us in successfully overcoming the challenges of the twenty-first century.
1. Declaración de Alma-Ata. In: Alma-Ata 1978: atención primaria de salud. Informe de la Conferencia Internacional sobre Atención Primaria de Salud; septiembre 612 de 1978; Alma-Ata, URSS. Ginebra: Organización Mundial de la Salud; 1978. Pp. 34. Available from: http://www.paho.org/spanish/dd/pin/Alma Ata_declaracion. htm. Accessed 31 July 2006.
2. World Health Organization. Macroeconomics and health: investing in health for economic development. Geneva: WHO; 2001.
3. People's Health Movement, ed. Health for all now! Revive Alma Ata!! The Alma Ata anniversary pack. Bangalore: People's Health Movement; 2003.
4. Schneider MC, Castillo-Salgado C, Loyola-Elizondo E, Bacallao J, Mujica OJ, Vidaurre M, et al. Trends in infant mortality inequalities in the Americas: 1955 1995. J Epidemiol Community Health. 2002;56(7):53841.
5. Organización Panamericana de la Salud. Atención primaria de salud. Los Objetivos de Desarrollo del Milenio en las Américas. Bol Epidemiol. 2004;25(2). Available from: http://www.paho.org/spanish/dd/ais/be_v25n2-mdgs.htm. Accessed 31 July 2006.
6. Caminal J, Starfield B, Sánchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health. 2004;14(3): 24651.
7. Klijzing F, Taylor H. The decline in infant mortality in Costa Rica, 19501973: modernization or technological diffusion? Malays J Trop Geogr. 1982;5:229.
8. Rosero-Bixby L. Infant mortality in Costa Rica: explaining the recent decline. Stud Fam Plann. 1986;17:5765.
9. Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the Cuban health paradox. J Public Health Policy. 2004;25(1):85110.
10. Castañeda T. Determinantes del descenso de la mortalidad infantil en Chile, 1975 1982. Cuad Econ. 1985;22:195214.
11. Svitone E, Garfield R, Vasconcelos M, Craveiro V. Primary health care lessons from the Northeast of Brazil. Rev Panam Salud Publica. 2000;7(5):293302.
12. Organización Panamericana de la Salud. Declaración de Boca Chica. Reunión del Sector Salud de Centroamérica y República Dominicana; 8 de julio de 2004; Boca Chica, República Dominicana. Available from: http://www.cor.ops-oms.org/ TextoCompleto/documentos/Declaración de Boca Chica.pdf. Accessed 31 July 2006.
13. Pan American Health Organization. Primary health care remains key. Available from: http://www.paho.org/English/DD/PIN/ptoday12_nov04.htm. Accessed 31 July 2006.
1 McGuire J. Social provisioning, socioeconomic context, and child mortality: a cross-national analysis. Annual Meeting of the American Political Science Association; 2002 Aug 29Sep 1; Boston, Massachusetts [unpublished document].