Entre a ausência em Alma-Ata e o Prevsaúde: a atenção primária à saúde no ocaso da ditadura / Between absence from Alma-Ata and Prevsaúde: primary health care in the twilight of the Brazilian dictatorship

Resumo Com base em documentos pessoais de Ernesto Geisel e matérias na imprensa, o artigo discorre sobre os bastidores da decisão de o Brasil não participar da Conferência Internacional sobre Atenção Primária à Saúde, realizada em 1978, em Alma-Ata, URSS. Sugere que os ministérios da Saúde e das Relações Exteriores avaliaram de maneiras distintas a importância da reunião no Cazaquistão, resultando em encaminhamentos conflitantes ao presidente da República. Estabelecida a ausência brasileira, o artigo traz contribuições acerca das formas pelas quais os preceitos consolidados na declaração de Alma-Ata foram compartilhados pelos círculos sanitaristas no país das mais distintas posições ideológicas, tendo inclusive orientado a formulação de programas ainda no regime militar e com implicações importantes sobre iniciativas posteriores.

Abstract Drawing on personal documents from Ernesto Geisel and press reports, this article discusses the background to the decision by Brazil not to take part in the International Conference on Primary Health Care held in Alma-Ata, USSR, in 1978. It is suggested that the Ministry of Health and the Ministry of Foreign Affairs had different views on the importance of the meeting in Kazakhstan, resulting in their submitting conflicting recommendations to the president of Brazil. It also investigates how the precepts consolidated in the Declaration of Alma-Ata were shared among Brazilian health specialists of different ideological persuasions, even to the point of serving as a blueprint for programs devised under the dictatorship, with implications for the development of later initiatives.

Status report on primary health care (1987-1993).

PIP: This article describes the legislative mandate for the development of primary health care (PHC) in the Philippines and provides a discussion of the attempts made to realize the goals of that mandate. Two major Department of Health thrusts are delineated: 1) from 1986 to 1991 Under-Secretary Alfredo Bengzon sought to deemphasize the implementation of primary health care in favor of an approach which sought to forge partnerships with nongovernmental organizations (NGOs) to realize a concept of "Community Health Development" and 2) from 1992 to 1995, Secretary Juan Flavier restored attention to the implementation of PHC which would be operational under the guidance of local government units. The difference in the two approaches is primarily a difference in their manner of execution. Despite some problems, the first initiative achieved important goals such as 1) implementing an information system to allow targeting of areas for social development, 2) organizing the First National Convention of NGOs for Health, 3) encouraging collaborative activities with NGOs, and 4) support of the activities of Barangay Health Workers (BHWs). The second initiative involved recognition of additional volunteer health workers; following community organizing as a basic approach for empowerment; expanding the prior initiatives; and making plans to identify model PHC barangays, monitor levels of PHC implementation, and prepare a BHW operational manual. This review ends by considering various issues and offering recommendations which include: 1) spelling out the role of local chief executives, 2) adopting a single terminology to describe the current approach, 3) defining the role of the BHW (multipurpose worker or health worker), 4) adopting a convergence of efforts strategy, 5) monitoring levels of PHC, 6) documenting the PHC implementation process, 7) dealing with program sustainability issues, and 8) improving the management of local health facilities.^ieng

The public health nurse--the linchpin of primary health care.

Finland is an example of a country in which primary health care has been put successfully into practice. This could not have been done without the help of public health nurses. At a time when socioeconomic and health status was low, a simple and effective public health nursing service was created to bring primary care to people in their homes and neighbourhoods.

PIP: Public health nursing (PHN) in Finland goes back to the start of the 20th century. Then, the country was poor, agrarian, and had a high birth rate; infant mortality was high. The frontline worker in an economical model of health care delivery to local communities was a nurse who had special training in preventive medicine. In developing the public health nursing service, Finland's people studies education methods and practice in use elsewhere. A family-centered service was seen as the most useful and economic form for Finland. The local "communes" organized the basic services, financed by communal taxes and state aid. The public health nurse was to try to change habits harmful to health. The state took over education of nurses in 1931. In 1944, a network of maternal-child health (MCH) centers, and public health nurses and communal midwives was started with 1 public health nurse for every 4000 inhabitants. The community health team was made up of a physician, midwife, and public health nurse. MCH centers were located in small quarters called "health houses." Also, care was given in village-level subcenters. Home visits by the public health nurse and midwife were important. Their services were free and available to everyone. A unique feature of MCH in Finland is that practically all mothers use it and do to this day, although it is not compulsory. The public health nurse worked for the local health board. Her supervisor was a local medical officer. The service emphasizes health promotion, primary prevention and health maintenance, and also acute and tertiary care. These duties require much education. At least once every 10 years, public health nurses were required to take an additional course to help them maintain their skills. From 1950 on, much work went into creating a network of central hospitals. Nurses had to be responsible for smaller districts. Services were reorganized in 1972 with the new Public Health Act. Home visits were reduced. The public health nurse is still a key person in primary health care. PHN education has been expanded to 4 1/2 years, including 3 years of general nursing education.

WHO: reaching out to all.

PIP: This article explains how the concept of health for all developed within the context of the history of the World Health Organization (WHO). By the early 1970s a new idea was taking shape in WHO. Medical services were failing to reach vast numbers. Health would have to emerge from the people themselves. In the heat of discussion the new strategy was clarified and given a name--primary health care (PHC). An ambitious target was set for it--no less than health for all by the year 2000. It was decided that the community itself had to be involved in planning and implementing its own health care. A new type of health worker was called for, chosen by the people from among themselves and responsible to the community but supported by the entire health system. In virtually all countries, the emphasis on curative care would have to be balanced by an equal emphasis on prevention. Almost 90% of WHO's Member States were prepared to share with one another detailed information about the problems facing their health systems. Industrial countries were beginning to realize that sophisticated medical technology was no guarantee of good health and that health for all through PHC offered an alternative. Millions of health workers have been trained, extending services to low-income groups that had no access to modern health care. Among health professionals, lack of understanding of the PHC concept and insufficient concern for social equity remain the principal constraints. Another problem is that expenditure on health care tends to be viewed as a drain on scarce resources rather than as an investment in the nation's future. The mommentum of health for all can be sustained only by governments implementing at home the policies they have collectively agreed on at The World Health Assembly in Geneva.^ieng

Myths and misconceptions in primary health care: lessons from experience.

Primary health care (PHC) is neither new nor cheap. It is a step forward in the consistent commitment of the public health movement over the past century and a half to seek out and redress the wrongs of society, paying particular attention to those most in need. PHC is not 2nd class medicine; it is not simpler but rather more complex. Selective PHC and primary medical care are significant parts of PHC but not the whole. PHC is essentially a combination of task-oriented basic health services and process-oriented community development. The former is a community-desired service, the latter less so. Community participation and community self-help in health care is more productive if based on an informed community, rather than otherwise, and is open to abuse. Health education and health legislation are the trusted tools of health advancement. Medical schools and other institutions of higher learning have a significant, if not vital, role to play in research education, evaluation, and services. They also have a coordinating role to promote PHC team effort. The selection and preparation of voluntary health workers and paid auxiliaries is at least as difficult as that for professional health workers. The preparation of their teachers is a sadly neglected aspect, without which there is little hope of any major progress in improving the image of PHC. Traditional practitioners could and should have an important role in promoting modern PHC since it is simply an update of their traditional role. Data and information systems require revision to meet the needs of local communities rather than those of central intelligence.

Primary health care in the People's Republic of China.

In scarcely more than 30 years, the People's Republic of China has progressed from limited health care available only to a privileged few to a countrywide system providing basic services to one fifth of the world's population. The author gives his impressions of the current situation, based on a recent visit.

PIP: There has been a marked improvement in the health status of China's 1 billion inhabitants during the last 20 years due to the government's decision to develop a primary health care (PHC) system rather than to promote a system of specialized health care for a small segment of the population. Chairman Mao emphasized that the major task of medical personnel was to provide care for workers, peasants, and military personnel. He advocated the use of both traditional and modern health care practices. During the cultural revolution medical training was sharply curtailed, but since 1977 medical training has been given a high priority. In recent years the major focus has been on providing PHC services for the workers in the cities and for the 80% of the population living in rural areas. At the present time there are 117 modern medical schools and 24 traditional schools. Even those enrolled at the modern schools receive some training in traditional medicine. Since 1977 modern medical training has been provided in a 5-year program, including a year of hospital internship. Students enter medical school immediately upon graduation from high school and must pass competitive exams prior to acceptance. The top members of the medical class are provided with additional training and prepared for research and teaching posions. The students in the lower portion of the class are assigned to rural areas and provincial hospitals upon graduation. Traditional medical school; emphasize preventive and promotive health care. Currently, health services are provided by 360,000 modern doctors, 250,000 traditionally trained physicians, 420,000 middle doctors, 1.6 million barefoot doctors, 400,000 nurses, 120,000 herbalists, and 70,000 midwives. Barefoot doctors are individuals elected by their fellow workers to receive training primarily in preventive heath care. Following training they serve as health educators for their follow workers. Middle doctors have varied training ranging from 6 months to several years and work primarily in urban or factory clinics. The progress made in the provision of PHC is evidenced in the increase in life expectancy from 35 years to 60-62 years during the last 3 decades. During this same period, infant mortality decreased from 11.76-1.035% and the maternal death rate decreased from 0.7-0.015%.