Promoting universal health through primary health care

Forty years ago, the Region of the Americas played a critical role in the development and negotiation of the Alma-Ata Declaration, which identified primary health care as a central strategy to the goal of health for all and a comprehensive approach to the organization of health systems. Since then, the values and principles of primary health care, which include the right to health, equity, solidarity, social justice and participation, and multisectoral action, among others, have formed the basis of many PAHO mandates and have guided health systems transformation in the Region. The positive impact of primary health care on the reduction of mortality, morbidity, and inequities in health is well known. (1) What's more, primary health care consumes less financial resources than curative approaches and promotes a chain of positive results from improved health to increased economic output, growth and productivity. (2)

In 2007, PAHO's position paper on Renewing Primary Health Care in the Americas included the definition of elements and functions of a primary healthcare-based health system with the intention of providing guidance to countries as they worked to transform their systems. (3) In 2014, the 53^rd PAHO Directing Council's resolution on Universal Access to Health and Universal Health Coverage (4) recognized the values and principles of Alma-Ata. The resolution urged PAHO Member States to promote intersectoral action to address social determinants of health and move toward health systems where all people and communities have access, without any discrimination, to comprehensive, appropriate and timely, quality health services, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services does not expose users to financial difficulties. (4) The Sustainable Health Agenda for the Americas 2018-2030, which represents the commitment of Member States to the 2030 Agenda for Sustainable Development and unfinished business from previous engagements, established areas of action that reinforce and complement the recommendations of the Alma-Ata Declaration. These include strengthening the national health authority; tackling health determinants; increasing social protection and access to quality health services; diminishing health inequalities among countries and inequities within them; reducing the risk and burden of disease; strengthening the management and development of health workers; harnessing knowledge, science, and technology; and strengthening health security. (5)

In the Region, the lessons that have been learned about the primary health care approach since Alma-Ata have been overwhelmingly positive. We have seen that countries that have implemented policies and programs based on primary health care have registered the lowest levels of infant and maternal mortality. Other achievements include improvement in public spending, increase in primary care services utilization, high immunization rates, a significant increase in coverage of antiretroviral treatment, and considerable decrease in infant, maternal and preventable mortality. These countries are implementing programs and policies that are saving lives in our Region. The average public expenditure on health in the Americas increased from 3.3% of the GDP in 1995 to 4.2% of the GDP in 2014. Mortality rates due to cardiovascular diseases declined 19% from 2000 to 2010 (20% in women and 18% in men); maternal mortality decreased from 99 per 100 000 live births in 2000 to 67 per 100 000 live births in 2015; infant mortality declined from 28 per 1 000 live births in 2000 to 15 per 1 000 live births in 2015; and antiretroviral therapy increased from 10% in 2000 to 53% in 2015. (6, 7)

Yet while there are many successes to celebrate, many challenges remain that must be recognized and addressed. These include the unfair and avoidable inequalities in health that still exist within and among countries in the Region, unacceptable barriers to accessing health services, inefficient hospital-centric models of care, segmentation of health systems, fragmentation of services, insufficient health financing, weak governance and leadership, increasing rates of suicide, and growing prevalence of noncommunicable diseases (NCDs) and their risk factors, to name a few. (6) Noteworthy is the fact that deaths by suicide and most NCDs are highly preventable through a comprehensive approach to primary health care. PAHO Member States have the opportunity to overcome these challenges by reforming their health systems by taking the primary health care approach and implementing public policies, programs and legislation that protect health and address risk factors. These systems are more resilient in the face of threats from epidemics, changes in the political landscape, and long-term social and economic instability than heath systems based on curative, hospital-centric models. PAHO is committed to working with its Member States to build precisely these kinds of health systems.

The Region of the Americas has proved to be one of the most dynamic regarding the transformation of health systems based on the primary health care approach and the implementation of health policies to advance towards the goal of universal access to health and universal health coverage. This special issue of the Pan American Journal of Public Health, timed to commemorate the 40^th anniversary of Alma-Ata, showcases innovative paths that countries have been taking to advance primary health care, strengthen health systems, and improve the health and well-being of their populations. The articles in the issue provide valuable experiences and evidence that we hope will inform decisions and health policies in the Region going forward.

Appreciation.

The Pan American Journal of Public Health recognizes with appreciation the contributions of the members of the Editorial Committee. Their dedication to this issue on primary health care helped make the manuscripts more interesting, more accurate, and more useful to our readers and all others who work to improve the health of the peoples of the Americas.

Ximena Aguilera, Director, Epidemiology and Health Policy Center, Universidad del Desarrollo, Chile; Mauricio Bustamante, Ex-District Health Secretary, Bogotá, Colombia; James Fitzgerald, Director, Health Systems and Services, Pan American Health Organization, United States; Antoine Groulx, Deputy Director-General, Health Services and University Medicine, Ministry of Health and Social Services, Quebec, Canada; James Macinko, Professor, Department of Community Health Sciences, University of California, Los Angeles, United States; Hernan Montenegro, Coordinator, Services Organization and Clinical Interventions, World Health Organization, Switzerland; Sergio Minué, Specialist in Family and Community Medicine. Professor, Escuela Andaluza de Salud Pública, Spain; Tomás Pantoja, Associate Professor, Department of Family Medicine, Pontificia Universidad Católica, Chile; Jacqueline Ponzo, President, Family and Community Medicine Society, Uruguay.