THIS MONTH, IN WHICH WE CELEBRATE THE 30TH ANNIVERSARY of the creation of the Unified Health System (SUS) by the 1988 Citizen Constitution and 40 years of Alma Ata, the invitation to the debate on the directions and challenges of Primary Health Care (PHC) provided by this issue of 'Saúde em Debate' is very welcome and timely.

In these dark times, in which threats to the universal right to health and equitable access to quality health services are intensified, it is necessary to reflect on the challenges of health systems and the role of PHC in the composition of those systems. In these 30 years of SUS, it is important to recognize the significance of PHC in broadening access, improving health indicators and reducing social and regional inequalities. Such advances are the result of government policies such as the Family Health Strategy, the More Doctors Program, the Program for Access and Quality Improvement in Primary Health Care and the National Primary Health Care Policy in its first versions¹1 Brasil. Ministério da Saúde. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2012 [acesso em 2018 out 3]. Disponível em: Disponível em: http://dab.saude.gov.br/portaldab/biblioteca.php?conteudo=publicacoes/pnab.
http://dab.saude.gov.br/portaldab/biblio... .

At the national level, we are experiencing a political moment that is disturbed by threats to democracy and by an illegitimate government that promotes a draconian fiscal adjustment with freezing of the investments in health and education for 20 years, whose negative repercussions are already felt in the worsening of infant and maternal mortality indicators and return of epidemics of previously controlled transmissible diseases. The strategic political agenda for PHC in the SUS²2 Associação Brasileira de Saúde Coletiva. Contribuição da Rede de Pesquisa em APS/Abrasco para a formulação de uma agenda política estratégica para APS no SUS. In: XII Congresso Brasileiro de Saúde Coletiva; 2018 jul 26-29. Rio de Janeiro: Abrasco; 2018 [acesso em 2018 out 3]. Disponível em: Disponível em: http://rededepesquisaaps.org.br/wp-content/uploads/2018/07/Abrasco_Final_06.07.pdf.
http://rededepesquisaaps.org.br/wp-conte... , published here, summarizes those threats to PHC and to the SUS itself, and invites to action in defense of the continuity of the SUS as a universal public system.

The PHC Global Conference in Astana, Kazakhstan, organized by the World Health Organization (WHO) and the United Nations Children's Fund (Unicef), will be celebrating the 40th anniversary of Alma Ata. The versions of the Astana Declaration³3 World Health Organization. Borrador de Declaración. In: II Conferencia Internacional sobre Atención Primaria de la Salud: Hacia la Cobertura Universal de Salud y el Desarrollo Sostenible; 2018 out 25-26. Astaná: WHO; 2018 [acesso em 2018 set 20]. Disponível em: Disponível em: https://elagoraasociacioncivil.files.wordpress.com/2018/06/borrador-de-declaraciocc81n-ii-conf-aps-2018.pdf.
https://elagoraasociacioncivil.files.wor... , in preparation, put to public consultation, raise deep concern, as they promote setbacks in the defense of comprehensive PHC in universal public health systems in which access to health services is a right of citizenship. The Conference calls for the Universal Health Coverage (UHC) and subsumes PHC to universal health coverage. The significance of UHC coverage, as proposed by the WHO and the World Bank, prioritizes financial coverage, which does not guarantee the universal right to health and equitable access to health services as needed. In UHC's conception, the right to health is restricted to securing a limited basket of services, differentiated according to income groups, in a new approach to selective PHC that combines private insurance and minimum packages. Universal coverage expresses, in the health sector, neoliberal policies of fiscal austerity and adjustment that reduce the role of the State in guaranteeing rights to a minimum.

The Latin American Association of Social Medicine (Alames), in a position published in this journal⁴4 Associação Latinoamericana de Medicina Social. Declaración de ALAMES frente al intento de absorber la APS en la, muy cuestionada, Cobertura Universal de Salud (UHC). Altana: Alames; 2018 [acesso em 2018 out 3]. Disponível em: Disponível em: http://alames.org/index.php/documentos/declaraciones-de-la-asociacion/137-declaracion-de-alames-frente-al-intento-de-subsumir-la-aps-en-la-cus/file.
http://alames.org/index.php/documentos/d... , warns us to the important setbacks that the Astana Declaration may represent. It warns that the UHC, in addition to not guaranteeing access, is a mechanism that facilitates the expansion of the private sector with its inherent iniquities; emphasizes the stress given in the proposal of the new Declaration to the participation of the private sector with the lack of responsibility of the governments in the design of the systems and provision of services of health; it denounces the enormous economic interests of the industrial medical complex (insurers, pharmaceuticals, equipment industry) in the expansion of the private market and its monopolies that hinder access to services by imposing abusive prices and distanced production of health needs.

The Alames calls attention to the exacerbated patriotism of the Astana declaration that affirms greater possibilities of success in the present moment without mentioning the enormous and growing concentration of wealth, the threats to the democracy with nationalist right wing governments in the United States of America and Europe, and the neoliberal adjustment policies that deny human rights. It calls for Latin American governments to defend the universal right to health and universal health (coverage plus guarantees of access), a consignment that the Pan American Health Organization had to assume under pressure from democratic South American governments in recent years.

It is necessary to make pressure so that the Astana Declaration keeps the Alma Ata spirit of social justice and universal health, of recognition of the social determination of health-disease processes, of the inseparability between health and economic and social sustainable development, and of the ability to promote social participation for the construction of health systems and democratic societies. It must be a priority to mobilize governments and societies towards the construction of free and public universal health systems, drawn up on the basis of PHC models that contribute to the reduction of social inequalities and health promotion.

Ligia Giovanella
Scientific editor of 'Saúde em Debate' special '30 years of PHC in SUS: strategies for consolidation'
Oswaldo Cruz Foundation (Fiocruz), Center for Strategic Studies (CEE) - Rio de Janeiro (RJ), Brazil.Maria Lucia Frizon Rizzotto
Editor-in-chief of 'Saúde em Debate'
Western Paraná State University (Unioeste) - Cascavel (PR), Brazil.

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