Family Practice, 2016, Vol. 33, No.

3, 261–267
doi:10.1093/fampra/cmw013
Advance Access publication 21 March 2016

Health Service Research

Mapping primary health care renewal in South

America
Naydú Acosta Ramíreza,*, Ligia Giovanellab, Roman Vega Romerob,c,

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Herland Tejerina Silvad, Patty Fidelis de Almeidae, Gilberto Ríosf,
Hedwig Goedeg and Suelen Oliveirah
a
Department of Public Health, Pontificia Universidad Javeriana, Cali, Colombia, bDepartment of Administration
and Planning in Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, cPublic
Health Institute, Pontificia Universidad Javeriana, Bogotá, Colombia, dFaculty of Medicine, Universidad Mayor de
San Andrés, La Paz, Bolivia, eDepartment of Health Planning, Fluminense Federal University, Niterói, Brazil, fFaculty
of Medicine, Universidad de la República, Montevideo, Uruguay, gGoede Public Health Cons Bureau, Independent
Advisor, Paramaribo, Suriname and hFaculty of Psychology, Centro ABEU University, Rio de Janeiro, Brazil.

*Correspondence to Naydú Acosta Ramírez, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Calle 18
No. 118-250, Cali, Colombia; E-mail: naydu.acosta@javerianacali.edu.co

Abstract
Background.  Primary health care (PHC) renewal processes are currently ongoing in South America
(SA), but their characteristics have not been systematically described.
Objective.  The study aimed to describe and contrast the PHC approaches being implemented in
SA to provide knowledge of current conceptions, models and challenges.
Methods.  This multiple case study used a qualitative approach with technical visits to health
ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53
local managers, as well as field observation of 57 selected PHC providers and document analysis,
using a common matrix for data collection and analysis. PHC approaches were analysed by
triangulating sources using the following categories: PHC philosophy and conception, service
provision organization, intersectoral collaboration and social participation.
Results.  Primary health care models were identified in association with existing health system
types and the dynamics of PHC renewal in each country. A  neo-selective model was found in
three countries where coverage is segmented by private and public regimes; here, individual and
collective care are separated. A comprehensive approach similar to the Alma-Ata model was found
in seven countries where the public sector predominates and individual, family and community
care are coordinated under the responsibility of the same health care team.
Conclusions.  The process of implementing a renewed PHC approach is affected by how health
systems are funded and organized. Both models face many obstacles. In addition, care system
organization, intersectoral coordination and social participation are weak in most of the countries.

Key words. Comprehensive health care, health care reform, primary health care, social participation, South America, universal coverage.

Introduction yielding improvements in the health of populations, which is not a

recent concern.
Given the persistent challenges of health inequality and premature
In 1978, the Declaration of Alma-Ata reiterated that health is
mortality in the region of the Americas (1), there is growing inter-
a fundamental human right that must be respected, protected and
est in implementing systems and models of health care capable of

© The Author 2016. Published by Oxford University Press. All rights reserved.
261
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262
guaranteed to all the world’s peoples. It set out to establish a concept
of primary health care (PHC) strategy framed by a model in which
care is comprehensive and inseparable from economic, social and
cultural development, and involves health promotion, social par-
ticipation and intersectoral cooperation to address the social deter-
minants of health. Nonetheless, in the 1980s and 1990s, in many
countries focalized, selective models of PHC delivered by vertical
programs targeting vulnerable population groups or specific health
problems were developed. Since the 1990s, encouraged and financed
by multilateral finance agencies, some countries have carried out
health sector reforms with a market-economy approach centred
on competition and cost control, managed care, health insurance,
separation of individual and collective health risk management and
limited health benefit packages or focused insurance for marginal
population groups. These reforms have worsened social inequities
and the fragmentation of care and, by centring interventions on the
health sector, they have limited the reach of intersectoral action and
community participation (2).
Meanwhile, several studies have found improvements in health
indicators associated with the implementation of PHC (3,4)
as recommended at Alma-Ata. As a result, since 2005, the Pan
American Health Organization and subsequently the World Health
Organization have urged their member states to renew PHC with
universal coverage, promote equity in health and guarantee the uni-
versal right of access to health services.
Primary health care renewal processes are currently ongoing in
South America (SA), but their characteristics have not been exam-
ined systematically. Accordingly, this article aims to describe the
PHC approaches being implemented in the 12 countries of SA. It
aims to provide knowledge of current PHC conceptions, models and
challenges in the region by contrasting experiences so as to identify
and understand shared problems and the possible solutions encoun-
tered in each country. The latter may, in turn, serve to guide national
or regional policies towards building universal coverage systems and
comprehensive models of health care.
Methods
On a multiple case study approach, PHC was mapped in Argentina
(5), Bolivia (6), Brazil (7), Chile (8), Colombia (9), Ecuador (10),
Guyana (11), Paraguay (12), Peru (13), Suriname (14), Uruguay (15)
and Venezuela (16). A  qualitative approach was applied, starting
with definition of theoretical categories and application of multiple
data and information collection strategies. The fieldwork for data
collection included 12 meetings at health ministry offices, develop-
ing key-informant interviews of 129 PHC national policy makers
and 53 local managers, field observation of 57 selected PHC services
between November 2013 and April 2014, document analysis and a
literature review. The complete information sources by country are
available in the case study reports (5–16).
Information from the various sources was triangulated and ana-
lysed critically on the basis of the predefined matrix categories and
emerging empirical categories. The results were first presented in
country case study reports (5–16), which describe the components
of PHC implementation in the region. This article draws on those
mappings to characterize the PHC approaches in terms of selected
theoretical categories considered core components of comprehen-
sive PHC. The selected categories are as follows: key elements of
the PHC model (PHC philosophy and conception in health poli-
cies), organization of service provision (PHC team composition,
territorialization and integration with other levels of health care),
Family Practice, 2016, Vol. 33, No. 3
intersectoral cooperation (interaction with other public policy sec-
tors at the national level to address the social determinants of health)
and social participation (forms of user representation and participa-
tion in PHC). Based on the qualitative analysis process by triangulat-
ing among sources (17), the results contrast the experiences of each
country and identify common elements in PHC implementation in
relation to existing health system types and segmentation of popu-
lation coverage. Another study describes other categories and vari-
ables examined in the PHC mapping in the countries of SA, such as
the responsibilities and attributions of levels of government in PHC
implementation, funding and intercultural approaches (18).
Mapping in the 12 countries was coordinated and funded by
the South American Institute of Government in Health (ISAGS), an
international organization of the Health Council of the Union of
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South American Nations (UNASUR).
Results
The elements of philosophy and conceptions formally defined in leg-
islation or official documents of health policies in South American
countries are shown in Table  1. The commitment to PHC is high-
lighted in the policy documents in all South American countries.
With different approaches, the national policies incorporate the main
elements of the Alma Declaration. All countries mention comprehen-
sive care and seven countries describe a new care model (Table 1).
Three countries (Bolivia, Ecuador and Venezuela) also make a prior-
ity of health promotion, understood as intersectoral action on the
social determinants of health, plus social and community participa-
tion. In some countries, there is an emphasis on interculturalism,
including respect and assimilation of the know-how and practices
of Indigenous peoples. Examples are the ‘Modelo de Salud Familiar
Comunitario Intercultural’ in Bolivia (6), the ‘Modelo de Atención
Integral en Salud Familiar Comunitaria e Intercultural’ in Ecuador
(10), the intercultural PHC model among the Mapuche in Chile (8)
and the ‘Sistema Indígena Propio e Intercultural’ in Colombia (9).
In most countries, the PHC provision is organized on the basis of
two health facility types: posts and centres. Health posts serve small,
rural, dispersed populations and are generally staffed by nursing aux-
iliaries or community health workers (CHWs) (18). Health centre
teams (Table 2) commonly comprise a doctor, a nurse, nursing aux-
iliaries and sometimes a midwife, social assistant, dentist and dental
assistant. There are team variations within and between countries.
Sometimes, the teams are incomplete due to an insufficient supply
of health professionals. In six countries (Argentina, Chile, Guyana,
Paraguay, Peru and Uruguay), PHC teams include nurse-midwives,
midwives or obstetrics graduates. In other cases (for example, in
Venezuela and in Bogotá, the capital city of Colombia), there are
complementary teams comprising other health professionals, such
as psychologists, social workers and environmental technicians. In
nearly all the countries, PHC teams include paid or volunteer CHWs
to liaise between community and health services and perform extra-
mural and community tasks.
The supply of health professionals varies among countries, and
its internal distribution is extremely uneven. Even though no consist-
ent statistics are available on PHC human resources, the consensus is
that they are insufficient in number and their education and training
are inappropriate (i.e., not specifically designed for PHC activities).
In nearly all the countries, there is a range of new PHC training ini-
tiatives at all levels (technical, undergraduate, postgraduate and con-
tinuous professional development). Nine countries (Bolivia, Brazil,
Chile, Ecuador, Guyana, Peru, Suriname, Uruguay and Venezuela)
Mapping primary health care renewal 263

Table 1.  Elements of primary health care model (PHC philosophy and conception in health policies in South American countries)

Countries Conceptions of PHC in present policy

Argentina (2004) Health is considered a right, the responsibility of the state. Emphasis is on comprehensive care, disease prevention, health
promotion and rehabilitation, accessibility and health service decentralization. This gives the framework for various initia-
tives, including the ‘Remediar’ and ‘Médicos Comunitarios’ (PMC) programs (5).
Bolivia (2008) With its principles of community participation, intersectoral collaboration, interculturalism and comprehensive care, the
‘Modelo de Salud Familiar Comunitario Intercultural’ (SAFCI) comprises the elements of comprehensive PHC (6).
Brazil (2006, 2011) The ‘Política Nacional de Atenção Básica’ conceives comprehensive care as a set of actions for individual and collective
health, which are to affect the health situation, people’s autonomy and the social factors that determine and condition
collective health. The ‘Estrategia de Salud de la Familia’ (ESF), with its multi-profession teams, territorial basis and social
participation emphasis, is the main PHC delivery model (7).
Chile (2005, 2013) The ‘Modelo de Atención Integral de Salud, Familiar y Comunitaria’ emphasizes the equitable distribution of health care
resources so as to deliver essential health care in keeping with the Alma-Ata recommendations, with a bio-
psycho-social, user-centred approach. Features include integrated care, continuity, intersectoral cooperation, promotion and

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prevention, participation in health care, use of appropriate technology and quality (8).
Colombia (2011) PHC is defined normatively (Law 1438) as a national strategy for intersectoral coordination to permit comprehensive,
integrated care, extending from public health through health promotion, disease prevention, diagnosis, treatment and
rehabilitation, at all levels of complexity (9).
Ecuador (2008, 2012) Since the 2008 constitution, PHC has been specified as the base of the health system, grounded in comprehensive family
and community care, interconnecting the various levels of care and fostering complementation with ancestral and alterna-
tive medicine. The ‘Modelo de Atención Integral en Salud Familiar Comunitaria e Intercultural’ (MAIS-FCI) incorporates
the renewed PHC approach and states that it is the set of strategies that organises the National Health System in order to
meet the health needs of individuals, families, communities and environs (10).
Guyana (2013, 2010) The document ‘Visión de Salud 2020’ reaffirms the commitment to PHC and the importance of addressing the social deter-
minants of health. The health system is based on PHC; universal access to free health care is a constitutional right (1980)
and the emphasis is on health promotion and comprehensive care at the various levels of complexity (11).
Paraguay (2008) PHC is understood as a strategy that comprehensively comprises the health–illness process and care for individuals and
communities, with regard for their differing life stages. It provides health services and addresses the social, economic, politi-
cal and environmental root causes of ill health. Family health teams and facilities are assigned to specific territories in order
to increase access by excluded population groups (12).
Peru (2003, 2011) The ‘Modelo de Atención Integral de Salud Basado en la Familia y la Comunidad’ (MAIS-BFC) rests on the Alma-Ata
definition of PHC and the principles, values and strategies of renewed PHC, emphasizing promotion and prevention,
integration of public health services and personal care, development of a family- and community-directed orientation and
service quality improvement (13).
Suriname (2012) The national development plan ‘Suriname in Transformation 2012–2016’ assigns PHC the role—key to equity in health
and requiring multi-sector collaboration and social participation—of addressing social determinants, which are strategic
for dealing with chronic non-communicable diseases (14).
Uruguay (2007) Law 18.211, which institutes the Integrated National Health System, stipulates PHC as its strategy. Networks will be or-
ganized by levels of care, prioritizing the primary level, which will comprise a set of comprehensive, health sector activities
directed to individuals, families, communities and the environment, to meet basic health needs and improve quality of life,
to appropriate levels of resolution, with the participation of the human unit involved (15).
Venezuela (2004, 2014) Set up in 2004, the ‘Barrio Adentro’ mission explicitly makes PHC its fundamental strategy and stipulates that it is an
integral part of both the National Public Health System and of overall community social and economic development. It
constitutes the first level of contact between individuals, family and community with the National Public Health System.
The mission stresses accessibility, continuity and integration among the different levels of care and related networks, to
guarantee that health needs are met in a timely, regular and sufficient manner (16).

Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).

maintain cooperation agreements with Cuba to address the under-
supply of doctors for PHC.
One of the main problems in retaining doctors in public PHC
services lies in labour regulations. Employment relations and remu-
neration arrangements in PHC vary across all the countries. There
is a tendency towards more flexible and less stable labour relations,
including temporary, fixed-term contracts with fewer civil servants
in indefinite-term, budgeted positions. Instability of labour contracts
and lower salaries in the public sector hinder adhesion and prevent
the formation of bonds among the health team, families and com-
munity. Chile is the only country with a civil service career in PHC.
In most of the countries, PHC services are territorialized, with
user population allocation and health teams responsible for a spe-
cific, geographically defined target population (Table 2). The num-
ber of general population assigned per team varies from 1250
(Venezuela) to 3000 (Brazil) and 5000 (Chile). Community health
situation diagnosis and family records are not always in system-
atic use, although they are recommended as instruments for iden-
tifying socio-economic and health conditions to guide health team
responses in the community.
Integration of PHC with other health care providers, such as
those involved in secondary/specialist care, is a concern of policy
makers; in addition, in all the countries, primary-level services are
increasingly defined as the system gateway or the first-contact ser-
vice, and the PHC team is considered the gatekeeper for access
to specialized care. Nonetheless, officials recognize difficulties in
accessing specialized care, and they also realize that specialized and
emergency services are still often used for non-severe cases. Because
of short public supply, waiting times for specialized services are long,
but are almost never monitored or made public.
264 Family Practice, 2016, Vol. 33, No. 3

Table 2.  Organization of primary health care service provision in South American countries

Countries Composition of basic PHC teams at health centres PHC services territorialized: Number of general population
(‘Centros de Salud’) catchment area and population assigned per team
assignment

Argentina Medical doctors, nurse, nursing auxiliaries, midwives, Yes, uneven by state 3200–4000
dentists, paid CHWs
Bolivia Medical doctor, dentist, nursing auxiliary/technician, Yes, but allocation is developing 1000–20 000
volunteer CHWs
Brazil Family health team: medical doctor, nurse, 1–2 nursing Yes, population allocated per team 3000–4500 per family health team
auxiliaries/technicians, 5 or 6 paid CHWs in the Family Health Strategy
Oral health teams: dentist, oral health auxiliary and/or
technician
Chile Medical doctor, nurse, midwife, social assistant and Yes, population allocated per team; Up to 5000 per multidisciplinary
administrative assistant enrolment is on user initiative team

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Colombia No general rule on team composition. Primary health In some municipal models, no na- No general rule; depends on PHC
teams generally consist of medical doctors, general tional guidelines on sectorization of model in each territorial body
nurses, auxiliaries and health technicians, volunteer and PHC centres or user assignment
paid CHWs
Ecuador Medical doctors, nurse and PHC technician (paid CHWs) Yes, by circuits and districts; general 4000 in urban areas
population assignment
1500–2500 in rural areas
Guyana Medical doctor, nurse, midwife, laboratory assistant, aux- No assignment of users or general –
iliary pharmacist, dental assistant, rehabilitation assistant, population
environmental health assistant, Medex technician and
paid CHWs
Paraguay Medical doctor, graduate nurse and/or graduate in Yes, general population assigned per 3500–5000 (or 800 families)
obstetrics, nursing auxiliary and 3–5 paid CHWs. For family health team
every two family health teams, there is a dental team
consisting of a dentist and dental technician
Peru Medical doctor, obstetrics graduate, nurse, nursing Yes, primary health team users are 500–800 families assigned per
technician, volunteer CHWs registered by area of residence at the primary health team
closest primary-level health facility
Suriname Medical doctor, nurse, health assistant No general population or user as- –
signment
Uruguay Family or general practitioner, nurse, midwife, No general population or user as- –
paediatrician and visiting gynaecologist (basic team in signment
Montevideo)
Venezuela Comprehensive general practitioner, nurse, paid primary care Yes, user population assigned by 1250 users or 250–350 families
CHW ‘Barrio Adentro’ teams per team

Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).

Intersectoral collaboration to address social determinants and
promote health is another core component of comprehensive PHC.
All countries’ PHC policies specify health promotion, conceived as
action on social determinants and/or lifestyle changes, to be a key
component (Table  1). Argentina, Chile, Colombia, Ecuador and
Peru provide for nationwide intersectoral bodies. Bolivia, Brazil and
Uruguay have national programmes, while Guyana, Paraguay and
Venezuela have regional or local indicatives. At the territory level,
in all countries, PHC teams take initiative to coordinate local inter-
sectoral actions, with strong variations between countries (Table 3).
Bolivia, Ecuador and Venezuela are conspicuous for strongly inter-
sectoral approaches to deploying public policy on the ‘living well’
paradigm. These involve integrated sets of social development poli-
cies in which different sectors converge. Several actions have been
undertaken with potential positive impacts on the social determi-
nants of health.
With the exception of Suriname and Argentina, in all South
American countries, social participation in health is formally institu-
tionalized through national and local health councils (Table 3). The
community action of PHC teams is generally intended to mobilize
social participation for specific actions and empower the population
to pressure governments to ensure public policies such as garbage
collection, sanitation and access to clean water. In most countries,
the initiatives are sparse.
In terms of outputs and outcomes, the effect on population
health of the various PHC systems is difficult to assess because of
the variety of starting points and the myriad of confounding fac-
tors, such as economic and social determinants of health. This is a
limitation of this qualitative research that should be resolved with a
quantitative study. All countries show improvements in the mortal-
ity rate of infants and children under five, which could be related to
the poverty reduction since 2000 in the region (19). Nonetheless, in
a 2000–12 comparison, countries with renewed models of PHC that
focus on comprehensive, family and community care, such as Brazil,
Bolivia, Ecuador and Peru, seem to have better gains (Table 4). Chile
and Uruguay have the best results in both years.
Discussion and conclusions
Today PHC is being revitalized in a diversity of processes that are
underway in SA involving new models of family, community and
intercultural care. New policies and renewed models of PHC are
being implemented in seven countries (Bolivia, Brazil, Chile, Ecuador,
Paraguay, Peru and Venezuela) that include a common mention of
Mapping primary health care renewal 265

Table 3.  Intersectoral cooperation and social participation in primary health care in South American countries

Countries Arrangements to develop intersectoral cooperation Social participation

Argentina Intersectoral initiatives occur on the National Social Policy Coordination Informal arrangements: local councils; in the territory,
Council, the Inter-Ministry Mental Health Program and the Community they coordinate with community organizations, social
Health Facilitator Training Program. In the municipalities, these converge in clubs and non-governmental organizations (NGOs)
the Community Integration Centres, involving actions by the Ministries of
Health, Social Development, Labour and Planning and the Social Cabinet.
Locally, the PHC teams pursue intersectoral actions through the ‘Abordaje
Territorial’ and ‘Cuidarse en Salud’ programs.
Bolivia The main intersectoral policy is the Zero Malnutrition Multi-Sector Program Formal arrangements: committees and councils at the
(involving 11 ministries, state and municipal governments and NGOs). At the national, state, municipal and local levels
local level, primary health teams relate with other sectors for specific activi-
ties in education, urban cleansing and so on.
Brazil One of the main intersectoral social development policies is the ‘Programa Formal arrangements: Health Councils at the national,

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Bolsa Familia’, which transfers income to poor families, with conditionali- state, municipal and local levels
ties including health actions with the support of family health teams. In the
territory, these teams must mediate intersectoral actions to address the social
determinants of health.
Chile Intersectoral Action for Health (IAH), in place at all levels, is coordinated by Formal arrangements: Local Health Councils and Local
the Ministry of Health and local governments. PHC health teams work with Development Centres in each municipality
IAH by pursuing social protection programs and through the ‘Vida Chile’
committees, which implement promotion policies with health team and com-
munity participation.
Colombia A number of intersectoral committees have been set up at the national level, Formal arrangements: Community Participation Com-
among them the National Intersectoral Committee on Public Health, to guide mittees, Local Social Planning Councils, Local Health
interventions on the social determinants of health. Territory-level Councils, hospital boards
intersectoral coordination and participation PHC teams is limited to a few
municipal ventures.
Ecuador At the national level, the Ministry of Social Development is tasked with Formal arrangements: Local Health Committee in PHC
connecting the ministries of Sport, Housing, Education, Environment, Human facilities, Civic Health Sector Council
Mobility and Health to introduce intersectoral programs in the administrative
zones. At the local level, PHC teams interrelate with other sectors for specific
outreach activities, mainly in schools.
Guyana Intersectoral collaboration is facilitated through the ‘Consejo Democrático Formal arrangements: Neighbourhood Councils and
Regional’, which is a government administrative body responsible for social Village Councils.
services in the regions. Participation institutionalized in the Constitution
Paraguay At the territory level, Family Health Units coordinate their actions with state Formal arrangements: Local Health Councils and Sub-
and municipal governments and community organizations, such as NGOs, councils
Neighbourhood Committees and Local Health Councils. PHC team interac-
tion with community organizations and NGOs in the territory depends on
the self-management of each Family Health Unit.
Peru At the national level, the General Directorate for Health Promotion sets out Formal arrangements: Communal Surveillance Systems,
action plans and joint work pathways among sectors. The Integrated PHC Local Development Committees
Networks involve participation by the Health and Education Secretariat,
Ministry of Housing and the community sector, forming an intersectoral
committee that sets up a territorial health plan and health promotion actions.
At the local level, PHC teams conduct health diagnosis by geographical
sector, set up family and community care plans and sign communal commit-
ments to involve the local population and galvanize intersectoral actions.
Suriname At the district and community level, Public Health Secretariats, Regional No formal arrangements for social participation
Health Services and the Medical Mission engage in intersectoral initiatives.
The Public Health Secretariat collaborates with other sectors, especially in
environmental health, with the participation of local organizations.
Uruguay One of the key experiences in national intersectoral policy is ‘Uruguay Crece Formal arrangements: National Board of Health,
Contigo’, which fosters interventions focused on zones of extreme poverty, Advisory Councils, State Boards of Health. Informal
coordinated by the Planning and Budget Office of the Presidency of the arrangements: neighbourhood or support committees
Republic, with the Ministry of Health and other ministries. In the territory,
intersectoral collaboration is based on this policy, combined with actions
suited to local situations, and interacting with formal or informal State or
community organizations with a territorial presence.
Venezuela The ‘Barrio Adentro’ mission is conceived to be a space integrating all social Formal arrangements: Communal Councils and Local
sectors under the principle of ‘buen vivir’ (‘living well’). Health teams have a Health Committees
permanent relationship with the education sector and form part of compre-
hensive local development initiatives, e.g. by ‘Barrio Nuevo’ programs, which
address local problems with participation by all social development sectors.

Source: Adapted from Giovanella (25). The complete information sources by country (documents and interviews) are available in the case study reports (5–16).
266 Family Practice, 2016, Vol. 33, No. 3

Table 4.  Outcomes on population health of the primary health care systems in South American countries

Country Infant mortality rate Mortality rate under Maternal mortality % of children under % of births attended by
(per 1000 births) 5 years (per 1000 ratio (per 100 000 births) 1 year of age trained personnel
births) immunized against measles

Year 2012 Year 2000 Year 2012 Year 2000 Year 2012 Year 2000 Year 2012 Year 2000 Year 2012 Year 2000

Argentina 10.8 16.6 13.3 20.2 32.5 35 95 95 99.7 97.9

Bolivia 50 65 39.1 77.4 229 230 86 100 73.5 60.8
Brazil 14.5 27.4 16.5 32.9 61.6 89.7 100 100 99.1 96.7
Chile 7 8.9 8.2 10.9 15.7 18.7 97 97 99.8 99.8
Colombia 17.5 25.8 16.9 25.1 65.9 104.9 91 80 98.6 93.5
Ecuador 8.6 No data 22.5 34.3 45.7 No data 70 84 94.7 No data
Guyana 23.3 21.9 36.6 48.7 No data 133 98 86 98.3 90.3
Paraguay 14.6 20.2 21.9 33.5 96.3 164 73 92 96.8 No data

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Perú 17 33 16.7 39.8 93 185 89 97 91.4 59.3
Suriname 15.1 20.2 22.8 34.8 82.5 No data 85 71 90 90.6
Uruguay 7.8 14.1 11.1 16.8 18.6 No data 96 89 99.9 No data
Venezuela 14.9 19.4 14.9 21.3 69.8 60.1 89 84 99.5 No data

Source: PAHO (26).

comprehensive care, family focus and community focus with social
participation. Implementation is gradual, however, and many of the
policies have not yet fully achieved their expected results, as found
in some prior studies (20–23).
Tensions that remain as conceptions of PHC differ among and
within the countries, and the focus of implementation varies from
selective, focalized packages through emphasis on primary-level care
integrated into the care network, to experiences of strong commu-
nity action, intercultural approaches and impact on social inequali-
ties, with PHC integrated into a social development policy (as in the
‘living well’ paradigm).
Emerging empirical categories analysis show that the pro-
cess of PHC implementation can be seen to involve common ele-
ments relating to the existing modality of health systems and the
related segmentation of coverage. Prevailing assurance framework
rules stipulate separation and specialization of stewardship, fund-
ing, insurance and service provision functions, and the inclusion
of multiple public and private agents. The public subcomponent
of such systems on which PHC depends is generally designed to
protect the population with no means of payment and the lower-
income working population. Although insurance fund adminis-
tration models differ from country to country, the administrator
institutions are responsible for risk management, financial resource
management, user access and service provision procurement. These
characteristics of the health systems mean that, although national
governments respond formally for the approach to PHC design and
implementation (which are based on renewed PHC), the power of
the public or private institutions responsible for insurance funds is
decisive when it comes to defining PHC approach, funding organi-
zation and operating mode.
In this manner, two trends can be seen in how PHC models are
organized. One is associated with segmented health systems charac-
terized by individual risk-focused insurance, a market orientation
and separation into individual benefit packages and collective inter-
ventions, involving different sets of teams, one for individual care
and another for collective and community actions. The other model
is associated with health systems where the public sector and territo-
rialized state planning predominate, and where individual care and
collective and community interventions are coordinated under the
responsibility of the same health team.
Implementation of a comprehensive PHC approach encounters
the same obstacles as efforts to build universal health systems in SA
(24,25). It is conditioned and influenced by the prevailing modal-
ity of social protection in health. In countries where coverage is
segmented into private or public insurance, with service packages
differentiated by users’ ability to pay, the PHC approach comprises
packages centred on first-level individual care, with no territorial or
collective dimensions. In cases of subsidized insurance focalized on
low-income populations (or mothers and children or older adults),
the PHC focus is selective and based on a minimum service package.
This approach could be termed neo-selective PHC.
In countries seeking to build universal public health systems to
meet individual and collective needs regardless of ability to pay, PHC
being implemented is closer to the comprehensive approach proposed
at Alma-Ata. There, PHC is a strategy for coordinating health care by
ordering a comprehensive service network with social participation
and intersectoral action to address social determinants and promote
health, inseparably from national economic and social development.
The multilateral agencies’ PHC renewal proposals advocate PHC
as a strategy for reorienting health systems. However, this process is
conditioned by health system funding and organizational arrange-
ments. The segmentation of coverage and funding and the fragmen-
tation of care, which have worsened over recent decades, hinder
the implementation of comprehensive PHC, even in the context of
comprehensive care policy proposals. There is a need for the two
main existing models to be studied comparatively to evaluate their
impacts on health outcomes and on equity in health.
Declaration
Funding: South American Institute of Government in Health (ISAGS).
Resolution 06/2012 of the Health Council of UNASUR
Ethical approval: followed the ethical principles of the Declaration of Helsinki
and adhered to the Belmont Report principles, and obtained informed consent
from participants.
Conflict of interest: none.
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