Abstract
This article provides a description of integrated primary healthcare strategies in five Latin American countries to assess options for the implementation of a healthcare system based on Primary Care. Based on a document review of scientific articles and official documents from multilateral organisations, ministries, or health entities, it was possible to synthesise the Primary Health Care strategies that had been implemented to derive the main proposals that were potentially transferable. Argentina, Chile, Colombia, and Mexico have Primary Health Care actions aimed at promoting health and preventing diseases; Cuba is highlighted as a reference because of its family health model. The main difficulties are from healthcare system based on the neoliberal model and segmentation and fragmentation of healthcare services.This study provides important aspects of Primary Health Care, in terms of the need to revitalise with a family and community approach, integrating health services at three levels of primary prevention, intersectoral factors, community empowerment, resource allocation and training in human skills, as well as strengthening mental health and sexual health programmes. It concludes with suggestions for a more integrated Primary Health Care based on the strategies implemented and the local needs of the countries under study.
Background
In 1978, the World Health Organization and the United Nations Children’s Fund held the conference on primary healthcare in Alma-Ata, Kazakhstan. Defining it as
[A]n essential healthcare based on practical, scientifically founded and socially acceptable methods and technologies, made available to all individuals and families in the community, through their full participation and at a cost that the community and the country can support, in each and every stage of development, with a spirit of self-responsibility and self-determination. (World Health Organization, 1978)
A year after Alma-Ata, at a conference organised by the Rockefeller Foundation in Italy, participants and economists from the World Bank considered that the costs of primary health care from the ‘inclusive’ approach were extremely high. To reduce them and to address the main causes of death and illness, they proposed implementing more focused strategies such as vaccination, prolonged breastfeeding, family planning, and malaria control (Bhutta et al., 2018; Clavijo & Quesada, 2012).
Based on this proposal, in most of Latin America, the governments at that time converted primary care into a set of technical recommendations aimed at strengthening first-level healthcare system with specific programmes (Haggerty et al., 2009). Subsequently, a model began to emerge from the biopsychosocial approach in Latin America in the mid-1980s, integrating health interventions, citizen participation, community empowerment, and intersectoral collaboration (Organización Panamericana de la Salud y Organización Mundial de la Salud, 2008). Some governments proposed to implement primary healthcare as a care model to integrate their healthcare system (Ase & Burijovich, 2009), strengthening the public sector and moderating the expansion of the private sector (Atún et al., 2015). During this evolutionary process, the World Health Organization launched the Commission on Social Determinants of Health, which emphasised the need for primary healthcare in its final report in 2009 (World Health Organization/Commission on Social Determinants of Health, 2008), thus stimulating its rebirth and renovation in Latin America (Apraez, 2010).
Since its beginning, primary health care has been considered to be a public policy. It was proposed as a strategy to integrate and unify healthcare system, promoting self-care for a healthy life. Although there have been difficulties since its implementation, owing to its disagreement with Political Systems (Gómez, 2011), its components—that is to say, equity, social participation, healthcare promotion, and social determinants—made it possible to restore it as a vehicle towards improving healthcare provision.
In the recent Declaration of Astana (2018), the need to strengthen primary healthcare systems was emphasised. The success of PHC, as it is stated, will be driven by political will, knowledge, financing, human resources, and technology (World Health Organization and the United Nations Children’s Fund, 2018).
The primary objective of this article is to analyse PHC in the healthcare systems of countries that represent Latin America. In particular, the following specific objectives are met: (a) to identify integrated PHC strategies that are implemented in Argentina, Chile, Colombia, Cuba, and Mexico; (b) to review the main limitations that they have had to overcome and/or face, and (c) to determine the main challenges and future proposals that may be integrated into their respective healthcare system based on vigorous practices promoting healthcare and preventing disease.
Methods
The results of this article are part of a bibliographic research on official documents from multilateral organisations, ministries of health, and scientific articles identifying primary care as a strategy for comprehensive healthcare. First, five Latin American countries were selected: Argentina, Chile, Colombia, Cuba, and Mexico, taking into account the similarity of profiles observed among them in terms of primary care integrated strategies in maternal and child health programmes, sexual and reproductive health, non-transmissible diseases, and mental health, which have an impact on the population in terms of risk factors and health indicators. Similarly, strategic components such as public policy and the healthcare system are analysed. Cuba was considered a reference country owing to its advances and experience in primary healthcare.
Subsequently, a preliminary reading of the articles was performed, selecting those that fit the interests of the review and considering as inclusion factors those with a specific publishing interval from 2010 to 2020, as well as those considering strategies, scopes, and primary care potentialities, and finally, those being written in Spanish and English. Finally, the main strategies were implemented, and the limitations were established, trying to determine the main challenges to be achieved in primary healthcare.
Results
The results obtained for each country with respect to their approaches related to health systems, primary health care strategies, main restrictions and challenges to overcome are grouped below.
Characteristics of Healthcare System in Latin America
In most Latin American countries, there is a sharp segmentation of health services, characterised by having several organisational niches that act with unequal rules and service packages. These fragmentation and segmentation characteristics can be explained by the models in which Latin American healthcare system is included: unified public model, segmented model, public contract model, and private fragmented model (Bortoli & Zug, 2014). Table 1 summarises Latin American healthcare models and their main characteristics.
Healthcare Models in Latin America.
The main characteristics of the healthcare systems of the studied countries in terms of state health authority, health model, system characteristics, and financing are described in Table 2.
Health Model Characteristics in Latin America.
Primary Healthcare Strategies Applied by Countries
Countries that have implemented policies and programmes that focus on primary care have lower rates of morbidity and mortality (Tellez, 2015) as well as a positive trend in increasing promotion and prevention (Almeida et al.,2018). The most significant are listed below.
Argentina
Primary care strategies have been developed from a family and community perspective (Stolkiner et al., 2019). Among the first experiences are the Rural Health Program (1980) and the Outpatient and Home Care Programme developed between 1988 and 1989. The main healthcare focus includes provision of free essential medicines in primary care centres; thanks to this initiative, it was possible to reach the population without coverage, and thereby modify the guidelines for services used in a hospital-centric system and redirect the demand for primary services (Ardila et al., 2012).
In 2004, primary care was prioritised with the objective of developing an integrated healthcare system, some of the most important programmes being Mother and Child Programmes, the Community Medical Programme, and the Birth Plan (Abella, 2016). With the National School Health programme, prevention and promotion actions are promoted among school children and adolescents, redefining the concept of school health, where health and education are promoted in an integrated manner (Ministerio de salud de Argentina/Programa Nacional de Salud Escolar).
Sexual and reproductive health is enhanced through the National Programme of Sexual Health and Responsible Procreation, via the distribution of educational material, supplies, and personalised telephone care (Ministerio de salud de Argentina/salud sexual y reproductiva). For the prevention of sexually transmitted infections, the country has 3398 stationary distribution centres providing free condoms and 805 prevention, counselling, and HIV testing centres. In 2010, a strategy called ‘friendly clinics for sexual diversity’ was implemented in the country, which provided comprehensive care to this population group.
The Directorate of health promotion and the department of control of non-transmissible diseases of the Ministry of Health conduct national programmes to encourage healthy diet; obesity prevention; diabetes, cardiovascular, and respiratory disease control; and fight against sedentarism. The National Program of Active Aging and Health seeks to articulate actions aimed at the elderly from the perspective of active and healthy ageing. Following an integral and intersectoral approach, there is the programme for the development of the primary healthcare Strategy Strengthening Project (Ministerio de Salud de Argentina, 2009), and the National Health Program for Indigenous Peoples seeks to improve coverage and participation in health services (Ministerio de Salud de Argentina/Programa Nacional de Salud para los pueblos Indígenas, 2020). In addition, an App + Health project is being developed, which aims to articulate the systematisation and geo-referencing of information, enabling community monitoring and approach (Tetamanti et al., 2018). Alternatively, the national mental health law (2010) promotes the implementation of community-focused strategies.
Chile
Owing to its past democratic socialist struggle, Chile retains nuances of neoliberal reform that decentralised and privatised the public system, although it did not completely dismantle it (Ippolito, 2010). Primary care is provided based on a set of health establishments that have a welfare function within a given territory, and this is the gateway to the healthcare network (Inga, 2016). The Chilean health reform of 2005 adopted a scheme called Universal Access with Explicit Guarantees, which by 2012 constituted a wide primary care network that covered the entire country (Organización Panamericana de la Salud/Organización Mundial de la Salud, 2008).
The ‘Chile grows up with you’ programme constitutes a universal platform to support children’s development and pregnant women’s care (Atalah et al., 2014). Health professionals called ‘midwives’ are those who support gynaecological monitoring and perform interventions for family planning, prenatal monitoring, childbirth management, and post-partum period. Regarding sexual and reproductive health, the country has a national policy with three lines of action: a sexual and reproductive health programme within the health network, sexual and reproductive health mainstreaming, and intersectoral work. The National HIV/AIDS Plan aims to reduce the transmission of HIV through the promotion of safe sex.
In the prevention of non-transmissible diseases, campaigns are being carried out for the integral management of cancer and other tumours as well as cardiovascular disease, diabetes, kidney disease, respiratory disease, and epilepsy. The preventive medicine examination of the elderly promotes healthy ageing; the elderly are classified according to risk, subsequently developing preventive actions for patients’ treatment or rehabilitation (Ministerio de Salud de Chile, 2018). In the area of mental health, the 2017–2025 National Mental Health Plan, the National Suicide Prevention Program, and the National Alcohol Strategy have been developed. By means of the characterisation tool SALUFAM (Family Health), families of different levels of vulnerability can be identified with precision and predictive capacity (Puschel et al., 2012).
As a result of the call from the Pan-American Health Organization, Chile, by means of the Chilean Association of Nursing Education and Guild Associations, is currently working on implementing the role of Advanced Practice Nursing in primary healthcare by designing master’s programmes specialised in community and family nursing (Bustos, 2019). Furthermore, this country is training public health officials by means of diplomas and internships in neighbouring countries on the improvement of a comprehensive model with a family and community approach.
Colombia
The General System for Social Security in Health was created in 1993 with Act 100, subsequently amended by acts 1122 in 2007, 1438 in 2011, and 1751 in 2015. The 1438 act is reforming the healthcare system through a public health service delivery model within the framework of the primary healthcare strategy, enabling co-ordinated state action.
In 2016, the comprehensive healthcare policy was enacted, which includes the comprehensive healthcare model, which proposes promotion, healthcare, specific protection, early detection, and treatment and rehabilitation interventions throughout the life course. Together, the Ministry of Health and Social Protection developed the Comprehensive Healthcare Routes, which are made up of three sections: promoting and maintaining healthcare, healthcare for high risk groups, and specific care for events (Min Salud, 2016). In 2019, to ensure that healthcare is adjusted to territorial customs and needs, the Ministry of Social Protection proposed the Territorial Integral Action Model, which modifies the Comprehensive Health Policy (Min Salud, 2019).
Promotion and prevention actions that seek to improve maternal health are performed through the integral care route in perinatal maternal healthcare. In this context, it is important to highlight the Expanded Programme on Immunisations as it is the most modern and complete programme in Latin America, which manages to achieve 91.4% of coverage in children aged <1 year and 93.5% in children aged 1 year (Min Salud, 2021). In recent years, policies such as the Ten-Year Public Health Plan 2012–2021 and the National Sexuality Policy have been developed. The fact that the healthcare system
Regarding the prevention of sexually transmitted diseases, actions are performed to achieve a greater control over health, with awareness regarding condom use, prevention, post-exposure prophylaxis for HIV, sexually transmitted infections, and emergency contraception in victims of sexual violence (Min Salud, 2018). An early detection of non-transmissible diseases is performed in asymptomatic people by means of screenings that include analysing risk factors and addressing the diseases themselves, specifically to prevent cancer, diabetes, and primarily pulmonary and cardiovascular diseases.
The new National Mental Health Policy, presented at the end of 2018, seeks to prevent mental disorders by promoting coexistence and health in the environment, along with comprehensive and integrated care focused on primary care and intercultural adaptation, community-based rehabilitation, social inclusion, and sectoral and intersectoral coordination (Min Salud, 2018). The policy arises in response to the challenge posed by the fact that depression is the second cause of illness as well as the increase in suicide rates (from 4.4 in 2013 to 5.07 per 100,000 inhabitants in 2016) and attempted suicide rates (from 36.1 in 2016 to 52.4 per 100,000 inhabitants in 2017). Within the framework of the Mental Health Policy, the Integral Policy for the Prevention and Attention to the Consumption of Psychoactive Substances will begin to be structured.
Cuba
Primary healthcare has been the main stage of interventions for the integral improvement of the population’s health. The strength of the Cuban model in PHC is based on the physician who works under the concept of family doctor (Skeen & Zabala, 2018); in this manner, health coverage to the entire population is guaranteed. Among the main strategies and programmes implemented to strengthen primary care, the maternal and child strategy stands out, which is directed towards women’s reproductive health, the reduction of diseases associated with pregnancy and perinatal conditions, breastfeeding, and early cervical-uterine cancer diagnosis.
The early identification of pregnant women before12 weeks of gestation, has allowed to raise the quality of prenatal care. Thanks to active vaccination, coverage is >98.7% in children aged <1 year. Since 2016, the Cuban child population is protected from 13 vaccine-preventable conditions. In relation to sexual and reproductive health, strategies are developed with positive results through the National Commissions of Sexual Education and the Ministry of Public Health. The percentage of total contraceptive coverage has been >77% for more than a decade. Furthermore, it should be highlighted that condom use has increased by 2.4 times (González et al., 2018).
State policy respects the right to reproduction and provides the population with the necessary inputs to freely decide about their fertility. In the programme of non-transmissible diseases, interventions are developed for prevention and control of heart diseases, cerebrovascular diseases, asthma, diabetes mellitus, and alcohol and tobacco consumption. The Elderly Adult Programme uses grandparents’ circles and other community participation alternatives as a strategy. Mental health promotion is performed with prevention, early detection, and timely treatment, with the monitoring of cases with suicidal tendencies. This country has community mental health centres.
Mexico
In 1979, the extension of care coverage to the rural population began, which now has an extensive network of primary care centres (Bass, 2012). Intersectoral approach, community participation, appropriate technologies, and basic services along with traditional medicine are factors typical of this country. All these focus on community problems, proposing a self-care approach (Hevia, 2014). Presidential initiatives to address drugs and violence are highlighted through intersectoral action (Andrade et al., 2015).
The comprehensive healthcare model proposes that by 2025, the provision of health services can be guaranteed through an integrated model, focused on individuals, family, and community, with both preventive and curative characteristics. Recently, the Permanent Nursing Commission has worked on a project called the Nursing Integration Model to strengthen primary healthcare.
This country developed strategies from the maternal programme, the perinatal health programme, and the national breastfeeding strategy. Regarding sexual health, there is a programme of sexual reproductive health for adolescents, guidelines from the Interinstitutional Group for the Prevention of Pregnancy in Adolescents, and a sexual rights booklet is distributed among children and adolescents in the country for promoting sexual and reproductive healthcare to prevent unplanned pregnancies and sexually transmitted infections and eliminate child sexual abuse. This component is also strengthened by the National Strategy for the Prevention of Pregnancy in Adolescents (Gobierno de México, 2016).
With the national strategy for the prevention and control of overweight, obesity, and diabetes, strategic alliances are being established among different sectors. The main actions are aimed at reducing the consumption of tobacco and alcohol, promoting healthy eating, and promoting an active lifestyle that prevents obesity and reduces physical inactivity. In the area of mental health, intersectoral presidential initiatives are developed to address social emergencies such as drugs and violence.
Currently, the countries of Latin America are intensely facing the Coronavirus 2019 disease (COVID-19), caused by the SARS-CoV-2 virus with preventive measures of PHC to avoid the spread of the disease and achieve the flattening of the epidemiological curve (Álvarez & Harris, 2020). However, although a notable commitment from government entities has been evidenced, it must be even more intense and continuous to achieve not only the reduction of morbidity and mortality, but also in solving social, environmental, political, and economic problems. generated by this pandemic (Sánchez et al., 2020).
Restrictions and Limitations on Primary Care Proposals by Country
Implementation of PHC has not been easy; there is an apparent common will to redirect healthcare towards a preventive model. In Table 3, the limitations and challenges are highlighted by country, which are mainly associated with the model, system, health policies, and human talent training.
Limitations and Challenges in Health Latin American Countries.
Discussion
The PHC strategies implemented in the studied countries show considerable efforts in their development aimed at increasing health coverage and reducing morbidity and mortality indicators.
Regarding maternal and child health, it is evident that in all countries, there are programmes that address the mother–child binomial, executing strategies ranging from prenatal monitoring, birth and newborn care, promotion of breastfeeding, family planning advice, and early childhood monitoring to detect health disorders at an early stage. Regarding adolescents, countries have national strategies and policies developed in health institutions, communities, and schools, influencing the lifestyle of the individual. Cuba is an example to follow, providing continuous health education from preschool through university.
Although the countries studied have sexual and reproductive health strategies and policies, Latin America has high indicators of pregnancy at early ages. The highest rates are recorded in Argentina, Colombia, and Mexico, with the lowest in Cuba (Gianella et al., 2017). Preventive actions around non-transmissible diseases are aimed at improving lifestyles (Organización Mundial de la Salud, 2021); since early detection and timely treatment interventions have not been completely effective, there is an increase in mortality and disability owing to issues such as high blood pressure, diabetes mellitus, and cardiovascular diseases. Regarding transmissible diseases, they are channelled through HIV immunisation and prevention programmes. The increase in the rate of HIV infection in Latin America is a cause of concern, which has increased by 7% between 2010 and 2018. Chile has the largest number of new cases, which is 34%. Argentina has lower percentage ranges in this component.
In Mexico and Cuba, it has remained stable, whereas it has reduced by 22% in Colombia in the last eight years (UNAIDS, 2019). The integration of mental health in terms of promotion and prevention is almost nonexistent. The results of the last report made by the World Health Organization on Latin America showed that almost a quarter of disease is caused by mental health conditions, a situation that is concerning because it tends to increase. In Latin America, during the last 10 years, efforts have been made at the state level; although there are policies in countries such as Chile, which has established community centres to provide specialised care in PHC since 2015, and Colombia, with its recent enactment, the reality is that there is still much to do because of political instability and poor economic resources, among other factors (Troya et al., 2018).
Mental health services in most Latin American countries are provided through a curative approach for specific mental disorders and not from a promotion and prevention basis. Mental health remains a concern not only in Latin America but throughout the world. To facilitate integrated work in this area, more efforts should be employed to overcome inter-organisational segmentations and inter-professional differences to encourage joint work towards this purpose (Kohn et al., 2018).
The primary restrictions and limitations towards the development of primary healthcare are based on fragmentation, segmentation, lack of financial sustainability, health reforms, restricted community participation, and lack of continuity in health policies. Owing to the scarcity of resources that the different health systems have, primary care was observed as a solution; however, it is still limited owing to the lack of systematic training in the area and incentives for health professionals. To achieve effective primary care strategies, curricular changes in academia are needed to guarantee the development of skills and abilities that a professional must have for their work to be effective. Recent studies indicate that the most important factor associated with quality is related to better training and qualification of professionals (Peixoto et al., 2019). Interdisciplinary curricular changes towards primary care training are considered essential to establish an integrated system as well as for the effectiveness and efficiency of a health service (Carney et al., 2019).
Conclusions
When analysing the integrated PHC strategies implemented in Argentina, Chile, Colombia, Cuba, and Mexico, it is evident that all these countries share a desire to prioritise primary healthcare as a mechanism towards improving healthcare quality and access by means of policies and programmes in their health systems, aimed at modifying lifestyles and minimising risk factors. Cuba stands out from the rest, both for its coverage indicators and its access to health services, thanks to its state policy, which prioritises both the provision of health services and the supply of human resources for health at all levels of training and community participation. The strategies implemented show an important similarity between the Chilean and the Colombian health model; the difference lies in the strength of the public networks of the Colombian model, which has allowed a greater opportunity in the provision of promotion and prevention services.
The main difficulties in the development of primary care seem to arise from the neo-structural reforms of health systems based on the neoliberal model, where the market economies are those that benefit. This fact has led to healthcare being prioritised from a curative approach, being focused on specialised medicine and not primary healthcare and giving rise to the central hospital health model, which includes high cost technologies and high economic profitability for health providers. The Argentine health system is one of the most segmented and fragmented ones.
In terms of the Cuban family medicine model considered to be a referent for Latin American primary care, renewal is needed in terms of new technologies and resolving capacity, with no need to renounce its founding principles.
One of the main limitations of the health system in Cuba is the complex economic situation that the country is going through; however, despite this enormous difficulty, the Cuban health system is counteracted by its gratuitousness. Although countries have introduced important reforms in the financing and organisational structure of their systems, out-of-pocket expenditure remains high, with Argentina, Chile, and Mexico showing the highest expenditure.
Another difficulty is human health training, with Cuba being the differentiating country. Training in primary care, particularly in the case of doctors and nurses, is guaranteed from the system itself because it is considered the main basis for performing health interventions. This is one of Cuba’s strengths; however, it is the main weakness in the other countries, in which their human health resources do not have enough training in this area, which leads professionals to direct their work towards welfare.
The main challenges and future proposals for each studied country to integrate into their respective health systems would be oriented mainly towards strengthening the primary health care system. It is proposed that continuous efforts be made in the components of human talent, sexual and reproductive health, mental health, and community health. Mental health in current circumstances is considered a priority issue in PHC that requires continuity, due to the effects derived from social isolation for the prevention of COVID-19.
Footnotes
Declaration of Conflicting Interests
The authors declare that they have no potential conflict of interest regarding the research, authorship and/or publication of this article.
Funding
The authors did not receive any financial support for the research, authorship and/or publication of this article.