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The history of the National Basic Health Services Program (Prev-saúde) begins in 1979 with a joint effort involving the Ministries of Health, Social Security and Assistance, Interior, and Economy, as well as the Pan-American Health Organization. The objective was to reorganize basic health services in their connections with other levels of care. Internationally, it was part of the movement sparked by the International Conference on Primary Health Care in Alma-Ata in September 1978. Domestically, the program represented an accumulation of knowledge about the organization of services as well as a movement that was partially adapted to Brazilian health reform agenda. Prev-saúde was a set of health proposals that represented a technical consensus between bureaucracies and leaders of health reform.

Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

This paper illustrates the development of Primary Health Care (PHC) public sector in Malaysia, through a series of health reforms in addressing equitable access. Malaysia was a signatory to the Alma Ata Declaration in 1978. The opportunity provided the impetus to expand the Rural Health Services of the 1960s, guided by the principles of PHC which attempts to address the urban-rural divide to improve equity and accessibility. The review was made through several collation of literature searches from published and unpublished research papers, the Ministry of Health annual reports, the 5-year Malaysia Plans, National Statistics Department, on health systems programme and infrastructure developments in Malaysia. The Public Primary Care Health System has evolved progressively through five phases of organisational reforms and physical restructuring. It responded to growing needs over a 40-year period since the Alma Ata Declaration in 1978, keeping equity, accessibility, efficiency and universal health coverage consistently in the backdrop. There were improvements of maternal, infant mortality rates as well as accessibility to health services for the population. The PHC Reforms in Malaysia are the result of structured and strategic investment. However, there will be continuing dilemma between cost-effectiveness and equity. Hence, continuous efforts are required to look at opportunity costs of alternative strategies to provide the best available solution given the available resources and capacities. While recognising that health systems development is complex with several layers and influencing factors, this paper focuses on a small but crucial aspect that occupies much time and energies of front-line managers in the health.

Background: The Alma-Ata Declaration was a big step in the development of primary care, defining the main tasks and populations' expectation. Celebrating the 40th year's anniversary is a good opportunity to make an analysis. Development of primary care was not parallel in the Eastern and Western part of Europe., Aim: To provide an overview on the societal and economic situation, structural and financial changes of healthcare systems in the former 'Soviet bloc' countries, to present an analysis of the primary healthcare (PHC) provision and to find relationships between economic development and epidemiological changes of the respective countries., Method: Epidemiological data, healthcare expenditures and structure, and financing schemes were compared; systematic literature search was performed., Results: Visible improvements in population health, in the national economic condition, structural changes in healthcare and more focus to primary care were experienced everywhere. Higher life expectancies with high inter-country variation were observed in the former 'Soviet bloc' countries, although it could not be clearly linked to the development of healthcare system. PHC provision improved while structural changes were rarely initiated, often only as a project or model initiation. Single-handed practices are yet predominant. The gate-keeping system is usually weak; there were no effective initiatives to improve the education of nurses and to widen their competences. Migrations of workforce to Western countries become a real threat for the Central-East European countries., Conclusion: Lack of coordination between practices and interdisciplinary cooperation were recognized as the main barriers for further improvement in the structure.

Since the Alma Ata World Health Organization Conference in 1978, countries around the world have adopted institutions that promote the participation of citizens in their public health systems. The main objectives of this article are two-fold. First, we describe the origins and implementation of a national-level civic participatory program that was in place in Argentina in the mid-2000s: the Local Participatory Projects (Proyectos Locales Participativos). Second, we analyze the 201 local participatory projects that were carried out in Argentina between 2007 and 2008. We study health and environmental problems that prompt people's participation in the program and the social dynamics through which such participation is executed.

Access to health care has long been considered to be a human right. It was formally declared in 1946 when the heads of states wrote the constitution of the World Health Organization (WHO). But more than 70 years after the fact, the global community still has yet to achieve it.

Do early-life effects of investments in public health persist to the oldest-old ages? This article answers this question by using the primary care reform in rural Sweden that between 1890 and 1917 led to the establishment of local health districts, together with openings of hospitals and recruitments of medical personnel, as a natural experiment in early-life environmental conditions. The initiatives undertaken within these districts targeted control of infectious diseases, including various isolation and disinfection measures. This study applies a difference-in-differences method combined with propensity score matching to register-based individual-level data for Sweden from 1968 to 2012 and to multisource, purposely collected data on the reform implementation. Providing pioneering evidence for such a distal relationship (ages 78-95), this study finds that treatment through primary care in the year of birth leads to a significant reduction in all-cause mortality (4 % to 6%) and mortality from cardiovascular diseases (5 % to 6 %) and to an increase in average incomes (2 % to 3 %). The effects are universal and somewhat stronger among individuals from poor socioeconomic backgrounds and at higher baseline levels of disease burden.

Stronger primary care has been associated with important contributions to health system performance, yet countries struggle to resource it adequately, given competing demands from hospitals. Although historically China has originated influential models of primary health care, it has an enduring problem with hospital dominance in health service delivery. This paper is a historical analysis of the co-evolution of hospitals and primary care providers in China from 1835 (the year when the first hospital was built in mainland China) to 1949 (the year when the People's Republic of China was founded), which aims to shed light on approaches to primary care strengthening. We develop and use a path dependence analytic framework, specifying the critical juncture, conjuncture and post-juncture development of the institutions shaping the balance between hospitals and primary care providers in China. We find that China had historically formed the hospital-centric model involving four sets of regenerating and mutually reinforcing institutions: 1) financial resources were being disproportionally distributed to hospitals; 2) high-quality medical professionals were largely concentrated in hospitals; 3) large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients; 4) hospitals answered primarily to the demand of the more privileged social group. The early institutionalization of a hospital-centric model of Western medicine in China from 1835 became resistant to change, and efforts to strengthen primary care eventually took a divergent low-cost and de-professionalized developmental path towards 1949. As China still has a hospital-centric health system seeded in the nineteenth century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, China is unlikely to achieve a primary care orientation for health system development., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Competing Interests: Conflict of interest: none declared.

For the World Health Organization (WHO), the 1978 Alma-Ata Declaration marked a move away from the disease-specific and technologically-focused programmes of the 1950s and 1960s towards a reimagined strategy to provide 'Health for All by the Year 2000'. This new approach was centred on primary health care, a vision based on acceptable methods and appropriate technologies, devised in collaboration with communities and dependent on their full participation. Since 1948, the WHO had used mass communications strategies to publicise its initiatives and shape public attitudes, and the policy shift in the 1970s required a new visual strategy. In this context, community health workers (CHWs) played a central role as key visual identifiers of Health for All. This article examines a period of picturing and public information work on the part of the WHO regarding CHWs. It sets out to understand how the visual politics of the WHO changed to accommodate PHC as a new priority programme from the 1970s onwards. The argument tracks attempts to define CHWs and examines the techniques employed by the WHO during the 1970s and early 1980s to promote the concept to different audiences around the world. It then moves to explore how the process was evaluated, as well as the difficulties in procuring fresh imagery. Finally, the article traces these representations through the 1980s, when community approaches came under sustained pressure from external and internal factors and imagery took on the supplementary role of defending the concept.

POEMs (patient-oriented evidence that matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. For 20 years the authors of this article have reviewed more than 100 English language clinical journals monthly to identify POEMs in the medical literature relevant to primary care practice. This article identifies the POEMs in each of the last 20 years that were highest ranked for having recommended a major and persistent change in practice that year. They include POEMs that recommend a novel, effective intervention, a second group that recommends abandoning an ineffective practice, and a third group that recommends abandoning a potentially harmful practice. The top POEMs of the past 20 years illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature, such as that in POEMs, especially because many of these important articles did not appear in the primary care literature., (© 2018 Annals of Family Medicine, Inc.)

This article reflects on the history of the NHS in Wales and how this has led to its current structure. How this structure supports integrated working across primary, community and secondary care and how further integration with social care is moving forward and its direct effects on district nursing are explored. This article describes how district nursing is meeting these challenges. Support for district nurses as part of integrated multiprofessional teams is being developed to promote appropriately staffed teams centred on meeting the requirements of people within a designated area and ensuring that home is the best and first place of care.

High-quality primary health care (PHC) services are associated with better health outcomes and positive health equity. Providing PHC services to all inhabitants is one of the Chinese government's health care objectives. However, an imbalance between people's increasing health needs and effective health service utilization exists in China. The objective of this review is to identify evidence for PHC development in China and to summarize the challenges as a reference for the future improvement of China's PHC system. Literature searches related to China's PHC were performed in PubMed, Web of Science, China National Knowledge Infrastructure, and Wan-fang databases. Related data were collected from the China Statistical Yearbook on Health and Family Planning 2003-2016, the China National Health Accounts Report 2015, and An Analysis Report of National Health Services Survey in China, 2013. The PHC network and the population's health have improved in China in recent years, with general practitioners as "gatekeepers" who have gradually taken the initiative to offer health services to residents. The limitation of input and shortages of resources and skilled health care providers may restrict the sustainable development of China's PHC system. Therefore, policy support from the government is necessary., (Copyright © 2017 John Wiley & Sons, Ltd.)

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of today's health services predated the state's establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the country's small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the country's two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Key hefts, the hard core of clinical profile, scientific nursing and nowadays of the English School of Primary Care in the last sixty years are revisited. We understand that the most profound intellectual influence has been to Archie Cochrane, among family physicians hard core components we include John Fry (1922-1994), David Metcalfe and Julian Tudor Hart. On the other hand, Lisbeth Hockey (1918-2004), PhD in Nursing, was responsible for several years of Nursing Research Unit at the University of Edinburgh. The internet sources of English nursing historical research are very noticeable. Finally, Trisha Greenhalgh, family physician, researcher and Professor at the University of Oxford, is launching the old English School of Primary Care towards the middle of the XXI century.

A historic perspective of family medicine's development, the work of Gayle Stephens, and prior Keystone conferences constitute an important backdrop for the fourth Keystone Conference. Decisions made in the past constrain what can be done now, but they may also offer opportunities for family medicine. A major challenge for Keystone IV was to discern what is a constraint and what is an opportunity-in particular when it comes to the role of the personal physician. This article provides reflections based on decades of observation and study and confirms that knowing something and doing something are not the same., (© Copyright 2016 by the American Board of Family Medicine.)

Responsibilities for primary care clinicians are rapidly expanding ascomplexities in families' lives create increased disparities in health and developmental outcomes for young children. Despite the demands on primary care clinicians to promote health in the context of complex family and community factors, most primary care clinicians are operating in an environment of limited training and a shortage of resources for supporting families. Partnerships with evidence-based home visiting programs for very young children and their families can provide a resource that will help to reduce the impact of adverse early childhood experiences and facilitate health equity. Home visiting programs in the United States are typically voluntary and designed to be preventative in nature, although families are usually offered services based on significant risk criteria since the costs associated with universal approaches have been considered prohibitive. Programs may be funded within the health (physical orbehavioral/mental health), child welfare, early education, or early intervention systems or by private foundation dollars focused primarily on oneof the above systems (e.g., health), with a wide range of outcomes targeted by the programs and funders. Services may be primarily focused on the child, the parent, or parent-child interactions. Services include the development of targeted and individualized intervention strategies, better coaching of parents, and improved modeling of interactions that may assist struggling families. This paper provides a broad overview ofthe history of home visiting, theoretical bases of home visiting programs, key components of evidence-based models, outcomes typically targeted, research on effectiveness, cost information, challenges and benefits of home visiting, and funding/sustainability concerns. Significance for primary care clinicians isdescribed specifically and information relevant for clinicians is emphasized throughout the paper., (Copyright © 2016 Mosby, Inc. All rights reserved.)

Background: In the 1980s, PHC implementation promoted the health care delivery and overall health status of the population in Iran. Identifying the crucial design and implementation aspects of the PHC program can highlight the way it was implemented in a difficult sociopolitical environment. Using a policy analysis approach unfolds the details of implementation in a context which was not overtly convenient for a great health system reform., Methods: We conducted semi-structured interviews with 35 key participants and collected relevant literature and documents. We used a policy triangle framework to conceptualize the study and used a thematic data analysis approach to analyze the verbatim transcribed texts and documents. Data were analyzed with regard to the context, content, process and actors of the policy., Results: Proper use of the conditions and opportunities, during the first years after a revolutionary political change resulted in the establishment of a PHC network in Iran. Talented actors, clear content with agreed objectives and a top-down approach to the implementation in a special sociopolitical context were the main influential factors to fulfillment of the PHC policy in Iran. However, full implementation of the policy was hampered by the failure of some main components like referral system., Conclusion: The policy triangle framework helped us to separate the different components of the PHC policy denoting that successful implementation of a policy requires attention to all related elements. Policy actors should invest in the development of an effective advocacy coalition, while giving ample attention to the implementation concerns. National health policies can be materialized even during financial hardships, if they align with the wider expectations of the public and politicians.

Health risk assessments provide an opportunity to emphasise health promotion and disease prevention for individuals and populations at large. A key component of health risk assessments is the detailed collection of family health history information. This information is helpful in determining risk both for common chronic conditions and more rare diseases as well. While the concept of health risk assessments has been around since the Framingham Heart Study was launched in the 1950s, and such assessments are commonly performed in the workplace today, the US healthcare system has been slow to embrace them and the emphasis on prevention that they represent. Before wider implementation of health risk assessments within healthcare can be seen, several concerns must be addressed: (1) provider impact, (2) patient impact, (3) validity of patient-entered data and (4) health outcomes effect. Here, we describe recent developments in health risk assessment design that are helping to address these issues., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: According to the Organization for Economic Cooperation and Development, the Swiss healthcare system is one of the most effective in the world. Yet, as other occidental countries, it has to face the increase of chronic diseases frequency and its resulting cost, particularly for primary care (PC). However very few consistent data are available to describe PC features and its evolution over time. The aim of this study is to describe the evolution of the Swiss PC physicians' (PCPs) profile and activities between 1993 and 2012., Methods: The date come from two independent European surveys carried out in Switzerland respectively in 1993 and 2012. Both surveys were cross-sectional ones and based on representative samples of 200 PCPs, interviewed by questionnaire., Results: In 20 years, PCPs became older (median age 46 vs 56, p < 0.001) and more feminized (7 % vs 22 %, p < 0.001). Nowadays, they more often work in group practices (28 % vs 52 % in 2012, p < 0.001) and are more involved in other paid activities (28 % vs 66 % in 2012, p < 0.001). All the PCPs have a computer in 2012 (78 % in 1993, p < 0.001) and it is mostly used for keeping records of consultations (47 %). The number of daily face-to-face contacts with patients decreased from 31 to 24 but the average length rose from 15 to 20 min (p < 0.001). PCPs provide fewer pediatric and gynecological services but their activity remains globally unchanged in other domains. The frequency of meetings with other disciplines decreased significantly (e.g. once/month face-to-face meets with ambulatory specialists: 78 % vs 23 % in 2012, p < 0.001). The involvement of PCPs in follow-up and treatment of chronic disease globally little differed. In 2012, 8.5 % of the PCPs never performed any chirurgical acts (vs 0 % in 1993, p < 0.001)., Conclusion: This study showed a substantial evolution of Swiss PC over the last twenty years in terms of socio-demographic, organizational and service provided. The main changes include: feminization and ageing, lower diversity in services provided, fewer but longer consultations. These changes may have important implications for patients' management and will need to be considered for health planning purposes.

The access to ophthalmological care in Chile has been historically a problem. Only at the end of the twentieth century concrete solutions were promoted. In 1960, Primary Care Ophthalmologic Units were created to ease the access to ophthalmology, due to the efforts of Professor Juan Arentsen. Their functioning was organized and standardized subsequently using a model proposed by the Chilean Ophthalmologic Society, leading to a better patient flow and reducing waiting lists. These units became an innovative initiative to reduce the gaps in Chilean public health, optimizing the professional and infrastructural assets of the public health care system and achieving a new organization for the ophthalmological health care net.

The 2010 Institute of Medicine report, the Future of Nursing, recommended that nurses work to the "full extent of their training" to address the primary healthcare needs of United States citizens. This article identifies and describes historical antecedents, cornerstone documents, and legislative acts that served to set the stage for today, laying the groundwork for an expanded role for advanced practice nurses in the 21st century. Beginning with Lillian Wald's work in Henry Street Settlement in 1893, through Mary Breckenridge's founding of the Frontier Nursing Service in 1925, the discussion describes how nurses provided access to care for thousands of urban and rural citizens throughout the United States in the past. The article also discusses political forces at midcentury and the creation of the nurse practitioner role with the premise that nurses can learn from these early initiatives to create new models for nurses' roles in primary care today.