Public health and primary care. where are we going?

The COVID-19 pandemic has explored weaknesses and structural deficiencies in public health and primary care, and underscored the urgent need to change, redefine and modernize the health system. Interconnected, interoperable, and cooperative in an integrated manner, primary care and public health constitute the first line of containment and defense against disasters and epidemics. It is necessary to strengthen both to protect the second line of defense, the structure of hospital care. It is necessary to call for joint, agile, real-time, close and coordinated action between the two, to improve timely detection of new disease cases and to control transmission of the virus in the community. Kind words and little deeds abound these days.

We are being asked to “put on the shoes” of community health, and not to abandon the community orientation of primary care. The Ministry of Health approved in a regional council and published in the BOE on May 7, 2019, what would be the roadmap for autonomous communities, the “Strategic Framework for Primary and Community Care”, and recently, last September, all members of the Health Council of the Canary Islands gathered to highlight the importance of Invisible Community Health, among others.

It was the Public Health Act 1986, which ordered the merging of all health agencies (municipalities, councils, councils, cooperatives, etc.) and public health, to form what we would call in the future, the National Health System (SNS), thus ensuring health care in accordance with the 1978 constitution. And the truth is that many professionals, part of the population, and their representatives have created an image that public health, primary care, and community health are fundamentally different for different galaxies. However, all three have a common origin: the birth of cities, industrialization and the proletarian class, at the beginning of the nineteenth century; These phenomena were born, at the birth of what we today call public health, which were expressed in two different ways: first, as “urban or social hygiene” faced the dangers associated with overcrowding of the popular classes in the slums. cities (the London cholera epidemic of 1854), and another city, the so-called Worker Medicine, which responded to the need for fitter and healthier workers. Thus, clinics, health insurance for companies, unions, and finally the state were born. These two branches took two different and divergent paths: one, clinical care of labor medicine, the other, urban or social hygiene concerned with environmental and social issues, and later, bacteriological and microbiological health issues. The separation between medicine and hygiene, between treatment and prevention, between the individual and the group was reinforced. With the pandemic, we have all realized the need to restore a global and integrated vision for professionals. Individuals live, work and die in society, in their city and their surroundings and in their city, influenced by the many social and economic determinants of life.

It must be remembered that in the first two decades of the twentieth century, in the United States, community health centers were called those health centers that were born in the neighborhoods and neighborhoods of large cities to serve non-English speaking immigrant communities. After World War II and after the birth of the World Health Organization, this dual goal of ensuring the right to health and health care was launched. From the Declaration of Alma-Ata (1978), community health with the integrative purpose of the two original branches emerged with a motive. A few years later (1984, Basic Health Infrastructure Decree) the reform of primary care and the specialty of family and community medicine was born. Decades later, the proven progress and many failures of this reform are noted, especially in the field of citizen participation in health issues (Local Health Boards, Primary Health District), which is a right recognized and legalized in our country. A constitutional framework, but it is rarely reinforced by the health department, and its poor practices by the population. Years pass and we still do not have a regulation or a local development base, and we do not know whether we will see it before the end of the Legislative Council, or will it remain stuck in the drawer of the General Directorate of Public Affairs. Health or the Ministry of Health.

Little-known public health services, which have recently modernized their range of services, are trying to ensure that citizens maintain and improve their health, through epidemiological surveillance, reducing social determinants of health, promoting healthy environments and habits (example of the highly important and promising Xarxa Salut), and effective prevention of Disease through health policies and programs (prevention of colon cancer, vaccinations for children and adults, prevention of breast cancer, etc.). Public health faces the challenge of modernizing itself in order to respond with safeguards to the demands and needs of protecting the health of society. Aging, aging, climate change, air pollution and new emerging diseases are a challenge and a future challenge for the entire SNS. In order to bring health to our community, the active participation of all agents involved is essential.

The opinion of the Committee on Social and Economic Reconstruction of the House of Representatives, published in August 2020, includes in its conclusions the need to strengthen surveillance in the field of public health, and the development at the level of autonomous communities of public health structures granted. with the human, technological, and budgetary resources necessary to perform their functions effectively. In addition to promoting training and research applicable to public health policy and practice, under conditions equal to basic clinical and biomedical research. In Valencian society, more health investment is needed, after more than a decade without a public health job offer, and now, a generation of highly qualified and trained professionals are retiring with the risk of losing more epidemiological knowledge than that means. … the current and future reality tells us that the workforce, in terms of number and training, must be strengthened to meet new challenges and to incorporate new occupational traits, in line with the technological and multi-sectoral development that it must assume. A hundred times more is invested in healthcare than in public health. If more is not invested in prevention, we will not be prepared for the future pandemics that are sure to come (the planet says it all daily).

Public health expenditure statistics prepared by the Ministry of Health show that spending in Spain in 2019 amounted to €75,025 million, which is 6% of GDP, while spending per capita was €1,593 per capita. Primary care accounts for 14.2% of spending. Hospitals and specialized services accounted for the bulk, €44,001 million, representing 63.1% of expenditure: health expenditure on public health in 2019 amounted to 1.1% of the total, €823 million distributed to all autonomous communities. If you want public health and primary care, tell them in the budget. There is intelligent life outside of hospitals…and it is time to reflect, to see what we have learned, to plan and budget for all the human and technological means needed to meet the challenges of the future. Many professional, union, scientific, and citizen groups are calling for an additional 1% increase in public health GDP over four years, with the goal of budgeting more than 5% for public health and 25% for public health. Care.

In the Declaration of Alma-Ata in 1978, two questions were posed, which still exist today in the twenty-first century: Can a health and society approach be introduced into curative medicine? Can there be a health system that guarantees access to health (and not just health) for the entire population? We have two good news for our community: one, that in the future the Public Public Health Act 2011 will be developed (even if it is ten years away) and the second that it may be the headquarters of the future state public health agency. If public health, primary care and community health today seem to be three strange entities, it is not by chance, but rather it is a response to this deliberate separation and fragmentation by those who do not recognize these rights. By grouping them together, making the three convergence is easier if we know that they are actually three branches of the same tree. And there will always be someone who insists on trimming it. Public Health and Primary Care Where are we going?