Primary Care: Human Rights, Market, and the Brazilian Experience

 Authors: Victor Barbosa Assis, IFMSA Brazil UFPB

                  Victor Monteiro Pontes, IFMSA Brazil UPB

Primary care was a term used for the first time in Dawson’s Report in 1920, in the United Kingdom. The report made an evaluation, which concluded that the management of health services of the country were inadequate, since the advances in the medical-scientific field were increasing the prices of procedures, leaving methods that are more effective unavailable to a significant part of the population that depended on poor health care services.  Dawson’s Report advocated for the creation of a structure that allied preventive and healing medical care and organized in hierarchy systems, with a center of services in a defined geographical base. This document was used as reference for the creation of National Health Services (NHS) in 1948, a universal public health system conditioned only to the patient’s citizenship. (3, 5, 7).

In the International Conference on Primary Health Care in 1970 which created the Declaration of Alma-Ata (2), important landmarks were established. This included the consideration of Health as a fundamental human right and a demand for action from social, economic and health services sectors to reach the universalization of health coverage. It also promoted the idea that social and economic development, especially in developing countries, are associated with providing services that protect health care and advocate for it. Social and economic development was also deemed essential for the improvement of quality of life and reduction of disparities among socioeconomic groups inside the same territory as well as among developed and developing countries. It was a period of revitalization of the concept of primary care (1), since the conclusion was that because this type of care is essential but is based on methods and low-level technology, it can facilitate the access of the population to health care universally.

In the context of primary care, Starfield (3) concludes that governmental actions are essential by showing that the countries that provided such services presented significant improvement in mortality and mental health indicators as well as the population’s perception on how healthy they are feeling compared to countries that do not provide the same services. The researcher mentions other benefits such as larger access of less advantaged groups, reduction of inequity of health between groups and disease control before outbreaks, among others. Brazil is an example of this, since the effort put in making SUS available throughout the territory contributed significantly to the improvement in health indicators, eradication of diseases and reduction of disparities among regions of the country in regards to health care.

However, we must be cautious when associating  provision of primary care services to  Universal Healthcare Coverage in equality of conditions. If we compare North American, Latin American and European examples of health care services, there will be at least three types of models: 

• based on market, as it is in the American liberal model; 
• based on Universal Health Care (UHC), as it is in Colombia, and
• based on Universal Health System (UHS) as it is in Brazil. (4).

In the model practiced in USA (4), the market relations are predominant, since health is not a right, but merchandise. The government subsidizes vulnerable groups of the population through Medicare and Medicaid. However, despite the subsidies, there are still people uncovered. The practice of primary care and general medical access focuses on containing costs and reducing users.

Paim (6) brings attention to the fact that the term Primary Care or Primary Health Care described in the Declaration of Alma-Ata is incapable of being adaptable to many models of health care systems that differ from a model of Universal Health Service, which relies on public funding and provides wide access guaranteed only by condition of citizenship. The alternative model is UHC. It is applied in Colombia, in which the citizens and companies are obligated to hire health insurance to have some assistance; leaving the task of subsidizing health insurance to those that don’t have the minimum income to be insured to the government. Although this type of system is inserted in a market context that considers financial well-being of the individuals by avoiding insolvency due to direct payments for health services (4) as occurs in the American model, there is still a segmentation of the health system and inequality regarding the service’s offers among social groups, especially the poorest. For those who cannot afford, the only option is to accept the insurance with basic services (vaccines, medication and medical attendance) subsidized by the government. Of course, having some access to health care is better than none; however, this model is conditioned not by the patient’s citizenship, but by their economic conditions. Primary Care, therefore, in this case, refers to the minimal private service offered to a less advantaged population. The term, therefore, is more inserted in a context of structural reforms and reduction of State than in the context of a public policy by the mold of Dawson’s Report or the UHS model. We can also visualize some incompatibilities with the Declaration of Alma-Ata.

Because of its singular design, the Brazilian model chose an universal system of health funded by the government and organized in networks, providing universal and egalitarian access for all. The APS is the strategy used to reach universal coverage and it takes in consideration the population’s needs and health-disease factors, as much as allows local administrators to adapt the offered services by a health unity to the reality in which the community is inserted, all through territorialization. In the Sistema Único de Saúde (SUS) (4), in Brazil, the public health and individual demands are integrated with guaranteed care in all levels, without any restrictions of services. The primary care is shown to be effective through the APS, which offers collective and individual health services in remote and poor areas that, in other models, hardly would be covered. The SUS also ensures social participation in the process of construction and orientation of public policies, which agrees with the principles of the Declaration of Alma-Ata. This model of health care offers a notion of wide citizenship, which guarantees inclusion without depending on socioeconomic factors.

In the Brazilian health care system, most basic medical services are initiated with basic health units (UBS) and family health units (USF), which are responsible for attending the population contained on the covered area. These structures are tasked with providing clinical attendance: care for pregnant women, diabetics, hypertensives as well as routine check-ups with other patients. Furthermore, such an environment contributes to providing free medicaments for their patients to ensure the fulfillment of the treatments prescribed. It also promotes vaccination campaigns and provides a pack of vaccines to guarantee immunization, abiding by the rights every Brazilian citizen has since birth. It is also responsible for collecting materials for tests prescribed by the doctor in charge of the case. This outlook shows the importance of a public health care system to enforce primary care and to provide egalitarian and universal care. It is evident that such projects are not perfect and, therefore, present many difficulties to apply the proposed guidelines in its original legislation. Such adversities are related to a group of factors. Among them is the administrative improbability not only perpetrated by governors but also by local managers that are responsible for these unities or centers of primary care.

Generally, such infrastructures are extremely efficient, providing dozens of services daily. However, it is necessary  to have a more solid administration and investments in informational technology in order to optimize the management of patient flux in primary centers and transferences to more specialized centers. The optimization can be applied in the verification of how many beds are available in each attending center and unity, how many vacancies there are for care that is more specialized or for realization of tests. It might also be applied via the use of electronic medical records to facilitate access to clinical information of the patient by the medical staff responsible and the use of online pharmacies’ resources that would allow sharing of medicines and other medical materials with centers and unities that present with larger demand for medical resources. These measures are necessary, especially in regions with big centers that often encounter such problems along with lack of basic support for routine attendance, such as odontological and prenatal care. The overview presents the need of organization and endeavor in the administration and expansion of the primary care services, since for many Brazilians, it is the only form of access to the system of health care.

References:

1.GIOVANELLA, Ligia; ALMEIDA, Patty Fidelis de. Atenção primária integral e sistemas segmentados de saúde na América do Sul. Cadernos de Saúde Pública, v. 33, p. e00118816, 2017.

2.DECLARAÇÃO, DE ALMA-ATA. Conferência internacional sobre cuidados primários de saúde. Alma-ata, URSS, v. 6, p. a12, 1978

3. STARFIELD, Barbara; SHI, Leiyu; MACINKO, James. Contribution of primary care to health systems and health. The milbank quarterly, v. 83, n. 3, p. 457-502, 2005.

4.GIOVANELLA, Ligia et al. Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias. Ciência & Saúde Coletiva, v. 23, p. 1763-1776, 2018.

5.LAVRAS, Carmen. Atenção primária à saúde e a organização de redes regionais de atenção à saúde no Brasil. Saúde e Sociedade, v. 20, p. 867-874, 2011.

6.PAIM, Jairnilson Silva. Atenção Primária à Saúde: uma receita para todas as estações?. Saúde em debate, v. 36, p. 343-347, 2012

7.DAWSON, Bertrand Edward Dawson. Interim report on the future provision of medical and allied services. HM Stationery Office, 1920.