From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine. / De Alma-Ata a Astana: o percurso dos Cuidados de Saúde Primários em Portugal,1978-2018 e a génese da Medicina Familiar.

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.

Ao longo século XX, as profundas alterações que ocorreram na Medicina apenas podem ser completamente esclarecidas se forem observadas numa perspectiva histórica, pois elas sempre ocorreram em resposta a influências externas, umas científicas e tecnológicas, outras de ordem social. A moderna Medicina Familiar é uma das muitas disciplinas novas que se desenvolveram durante o curso da história da Medicina e aqui debatemos de forma crítica, os últimos 40 anos dos cuidados primários em saúde em Portugal, começando em 1971, mesmo antes da Declaração de Alma-Ata (1978). Ao longo do percurso, em 2005, surge a Reforma dos Cuidados Primários em Saúde em Portugal e as novas unidades de saúde familiar, que até setembro de 2019 atendiam cerca de 94% dos cidadãos portugueses, ou seja, mais de nove milhões e meio de pessoas. No final dessa trajetória, de forma solidária e voluntária, esta Reforma serviu de inspiração para outra, no Brasil, na cidade do Rio de Janeiro, em 2009. Por fim, apresentamos os desafios apontados na Declaração de Astana de 2018, dentre elas, a questão da força de trabalho nos cuidados de saúde primários, como fator essencial para o desempenho e a sustentabilidade dos sistemas de saúde.

De Alma-Ata a Astana: o percurso dos Cuidados de Saúde Primários em Portugal, 1978-2018 e a génese da Medicina Familiar / From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine

Resumo Ao longo século XX, as profundas alterações que ocorreram na Medicina apenas podem ser completamente esclarecidas se forem observadas numa perspectiva histórica, pois elas sempre ocorreram em resposta a influências externas, umas científicas e tecnológicas, outras de ordem social. A moderna Medicina Familiar é uma das muitas disciplinas novas que se desenvolveram durante o curso da história da Medicina e aqui debatemos de forma crítica, os últimos 40 anos dos cuidados primários em saúde em Portugal, começando em 1971, mesmo antes da Declaração de Alma-Ata (1978). Ao longo do percurso, em 2005, surge a Reforma dos Cuidados Primários em Saúde em Portugal e as novas unidades de saúde familiar, que até setembro de 2019 atendiam cerca de 94% dos cidadãos portugueses, ou seja, mais de nove milhões e meio de pessoas. No final dessa trajetória, de forma solidária e voluntária, esta Reforma serviu de inspiração para outra, no Brasil, na cidade do Rio de Janeiro, em 2009. Por fim, apresentamos os desafios apontados na Declaração de Astana de 2018, dentre elas, a questão da força de trabalho nos cuidados de saúde primários, como fator essencial para o desempenho e a sustentabilidade dos sistemas de saúde.

Abstract 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.

Health and health care in Israel: an introduction.

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.

Improving mental and physical health outcomes in general healthcare settings: a Gedenkschrift in honor of Wayne Katon, MD (1950-2015).

This special article pays tribute to Wayne Katon, MD (1950-2015) with a Gedenkschrift, or review, of his prolific academic career. Abstracts of all of Dr. Katon's Medline citations were reviewed to develop a narrative of his seminal epidemiological and interventional research findings. Specifically, we describe: (a) how Dr. Katon's clinical work and observational epidemiology and health services research informed and guided interventional studies; (b) the evolution of multidisciplinary interventional trials from primary care-based psychiatric consultation to primary care-based collaborative care for depression to multicondition collaborative care; and (c) how Dr. Katon's research has informed the work of other leading researchers in the field of psychosomatic medicine and helped develop a new generation of researchers at the interface of psychiatry and primary care. For more than three decades, Dr. Katon led a multidisciplinary research team that conducted seminal epidemiological studies and randomized trials and that influenced the thinking and research in the field of psychiatry in a number of areas: (a) the importance and impact of mental disorders presenting in primary care settings and (b) the organization of effective multidisciplinary care for primary care patients with common mental disorders and comorbid medical conditions. Dr. Katon's work revolutionized the care of psychiatric illnesses in primary care and other medical care settings to the benefit of countless patients worldwide.

The legacy of Michael Balint.

Michael Balint's lead article, "Repeat Prescription Patients: Are They An Identifiable Group?" inaugurated the first issue of Psychiatry in Medicine, Vol. 1, No. 1, 1970. A few years later, this Journal would be renamed International Journal of Psychiatry in Medicine (IJPM). Who is this author of over 165 papers, 10 books, practicing psychoanalyst from 1926 to 1970, director of the Budapest Psychoanalytic Institute from 1935 to 1939, consultant at the Tavistock Clinic from 1948 to 1961, President of the British Psycho-Analytical Society from 1968 to 1970, literary executor of Sandor Ferenczi, a foremost theorist of object relations, and international educator and statesman for general practitioners? We would like to review for you some of the formative experiences in Michael's life that wedded psychoanalysis and general practice, and how they contributed to his major educational commitment over 40 years to furthering the understanding and integration of psychosocial factors in the practice of primary healthcare as experienced by doctors all over the world. We would also like to highlight some of his major insights and see to what extent they are incorporated in contemporary medical education and practice. We believe that some of his major insights have been neglected and others have been further amplified and extended. Our intention is to speak not only to medical students who desire to pursue medicine related directly to patient care but as well to seasoned practitioners who continue on a daily basis to care for individual patients and their families.

Are we there yet? Seizing the moment to integrate medicine and public health.

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

A historical perspective of the women's health nurse practitioner.

There are more than 12,000 women's health nurse practitioners (WHNPs) currently certified by the National Certification Corporation (NCC) and practicing in a wide range of roles. The purpose of this article is to describe the historical development of the WHNP specialty, and to review the evolution of the specialty from an initially very focused practice in the area of family planning into obstetric and gynecologic care to today's more diffuse role inclusive of primary care. Women's health nurse practitioners must broaden their educational background to include the lifespan of women, not just the reproductive years. With the inclusion of chronic disease management of the middle-aged and elderly woman, WHNPs will provide more comprehensive and integrative health care to women in all areas of the United States.

[Alma Ata 30 years on. Evolution and perspectives of primary health care]. / A trent'anni da alma ata. Cure primarie: evoluzione storica e prospettive.

The Alma Ata Declaration (September 1978) was a turning point in the definition of "Primary Health Care". The traditional bio-medical model was based on a paternalistic approach and on the treatment of the individual episodes of disease. The new bio-psycho-social model was based on prevention, continuity of care, integrated health care teams and on a direct role of patients in managing their health. Thirty years on, this approach is still relevant. Actually, it is the only adequate one to answer effectively to the current challenges: epidemiological changes (increasing prevalence of chronic diseases), social changes (increased social inequalities in health), cultural changes (increased patients demand for information and autonomy).

Equity and the goal of health for all

There is a basic difference between the causes of diseases in population. We know that cigarette smoking causes cancer of the lung. If everyone in a population smoked, some would develop cancer, but we would never be able to identify tobacco as an etiologic factor. However, if one is seeking to enhance the health of populations, which is the main focus of public health, one has to be concerned with the distribution of the problems and the factors that influence such distribution in those populations. In the late 1970s the countries of the Caribbean, where I come from, were very advanced in their thinking about the steps to be taken to deal with population health issues, and they actually elaborated concepts that were very similar to those that subsequently were included under the heading of "primary health care." I found later that the Caribbean countries were not alone and that there was considerable ferment in public health circles in Latin America about the social causes of disease and the link between health and the various measures to achieve social progress. Health figured in the Pan American efforts to build a better future for the Americas. It could not have come as much of a surprise to the health authorities of this part of the world when the 30th World Health Assembly of the World Health Organization (WHO), in 1977, called for social justice and set Health for All as a goal. It is no accident that the main proponent and advocate of Health for All, Halfdan Mahler, of Denmark, was a man with a strong social conscience and was a firm believer in the possibility of galvanizing the world's nations to see the indecency of the differences in health that existed within and between nations (AU)

A look to the past, directions for the future.

This article represents the history of primary care and behavioral health integration at Group Health Cooperative (GHC) over the last decade, and foreshadows probable futures for this work into the next decade. To build from a logical progression, the article responds to a series of questions: 1. Why integrate primary care and behavioral health? 2. What has been done so far and how well has it worked? 3. Keeping the end in mind, what's the idealized picture of integration for the future? 4. How to get from here to there? What will help or hinder the effort? and 5. Again, why make these efforts to integrate?

Promoting traditional medicine in Ethiopia: a brief historical review of government policy.

Past and current official policy toward Ethiopian traditional medicine is reviewed. To facilitate the objective assessment of official policy, the nature and historical origins of Ethiopian traditional medicine is examined briefly. It is noted that there is no single system of traditional medicine in Ethiopia, even though themes that are common to the many cultural groups constituting the society have been evolving. Common to most systems of Ethiopian traditional medicine are the interdigitation of 'mystical' and 'natural' explanations of ill-health and other misfortune and the holistic approach employed in dealing with illness and other personal misfortune. It is also noted that since the 1974 change of government in Ethiopia, official attitude toward the promotion and development of traditional medicine appears to have become more positive, especially, after the adoption of the Primary Health Care strategy in 1978. While this is true as far as official statements are concerned, in actual practice there continues to be considerable uncertainty about the interpretation and implementation of Government policy. It is suggested that misconceptions regarding the nature and role of traditional medicine in Ethiopian society will have to be corrected if appropriate plans and strategies are to be formulated.

Reconocimiento y aceptacion de la labor de promotora, por parte de la comunidad de Cogua, Cundinamarca / Recognition and acceptance of the health promotor work, by the community of Cogua, Cundinamarca

Se realizo una encuesta de opinion para saber el reconocimiento y la aceptacion que el trabajo de la promotora de salud tiene en la comunidad y un cuestionario abierto para conocer la imagen que tiene la promotora de salud de su labor. Para el primero, se tomo una muestra estratificada de 231 familias del area rural de Cogua. Se considero reconocimiento o aceptacion el porcentaje igual o mayor que 60%respecto al significado de la promotora de salud, el 87%la definio como una persona da servicios de salud y previene enfermedad, y el 13%no la reconoce como agente de salud. En cuanto al conocimiento que tiene la comunidad sobre las actividades de la promotora, el 14%nombro mas de 5 y el 86%menos de 5. En relacion a la calidad del servicio, el 87%opina que es bueno porque beneficia la salud de la comunidad y el bienestar de las personas, y el 13%considera que es mala. Explorando las espectativas de la comunidad en relacion a la labor, el 72%espera colaboracion, capacitacion, atencion de consulta, el 28%no manifesto espectativas. El 79%cree importante la presencia de la promotora en la vereda. En caso de enfermedad, el 43%acude al medico y el 57%a la promotora. El 79%aplica sus ensenanzas. En el analisis del cuestionario dirigido a las promotoras de salud se encontro que se identifican como "voceras de salud de la comunidad", "el vinculo entre la comunidad y las agencias de salud" estan satisfechas con su labor de ayuda y orientacion sobre servicios de salud.

Primary health care in India.

PIP: Concurrently with the development of the general health services infrastructure in India, serveral special health programs were instituted at the national level to provide a massive and concentrated assault on the major public health problems of malaria, smallpox, cholera, trachoma, tuberculosis, leprosy, filariasis, and the rapid population growth. These vertical programs were expected to reduce the heavy morbidity and mortality within the shortest possible time to where they were no longer major public health problems. The impact was variable. Major steps toward providing integrated health care were taken during the first 5-year plan. Emphasis was on the provision of a packet of inttegrated health, family planning, and nutrition services to the vulnerable groups, i.e., children, pregnant women, and nursing mothers. To rectify past shortcomings ssuch as the failures of the national health programs, ineffective coordination in the nutrition programs, and slow rate of development as a result of interdependence of different sectors, it was necessary to improve the health infrastructure and to launch a frontal attack on poverty. The Multipurpose Health Workers Scheme was planned to rationalize the organization and use of available manpower to reduce the area and population covered by each of the field staff in order to reduce travel time and to make services more effective and more satisfactory. Each multipurpose health worker was entrusted with the task of providing comprehensive health care to about 5000 people. Communicable diseases were the main public health problems, and many specific control/eradication programs were launched. the immunization programs against common childhood diseases have not taken deep roots and coverage continues to be poor. The adoption of the Western model of medical services has resulted in emphasis on "cure" rather than on "care". Another problem is maldistribution of the facilities. Overemphasis on medical education has resulted in the relative neglect of development of health manpower for nursing, environmental engineering, and other technical and paramedical personnel. Community involvement and participation were at a minimum if they existed at all. The basic concern about primary health care for all continued unabated however. To realize the goal of health care for all, 3 programs will have to be pursued simultaneously during the next 2 decades: integrated overall development including family planning; improvement in nutrition, environment, and health education; and the provision of adequate health care services for all, particularly the poor and underprivileged. It is necessary to redefine the roles of the central and state governments in view of the large power powers delegated to local bodies at the district level and below. Voluntary agencies will have to function within the overall plan/aid down by the state.^ieng