The fulfillment of the goal of health for all by the year 2000 presents a formidable challenge to the imagination, technical capacity and spirit of service of those responsible for the political leadership, organization, administration and evaluation of systems for the provision of health services in the countries of the Americas.
This challenge is characterized by the requirements of equity, efficiency and effectiveness in health systems, as well as by the conditions of participation and intersectoral coordination indicated in the strategies and regional Plan of Action of PAHO.
Organization of health services
In most countries of the Region, there is a large quantitative deficit in the availability of health services for major population groups that still lack access to them. This reality is compounded by the rapid growth of theoretical demand related to changes in the volume, structure and distribution of the population, arising from the Region’s own demographic dynamics.
The combination of these factors, together with the worsening of problems related to financing, tends to perpetuate situations of limited coverage, low resource productivity and inequity in real access to and use of services by highly vulnerable and chronically underserved population groups.
The process by which service systems absorb health technologies is closely related to the degree of relevance that the technology and the characteristics of the infrastructure have in relation to the needs and demands of the population.
In reality, the primary healthcare approach suggests a broad frame of reference aimed at establishing the relationships among the mechanisms used to study and identify the population’s health needs, to select technological alternatives and solutions, and to define the requirements for organizing the resources that are ultimately responsible for carrying out activities devoted to improving the population’s health status.
According to some approaches, hospital services and primary care are incompatible, and the resources allocated to hospitals could be better used if they were directed toward primary care. In a diametrically opposite position, it is argued that, since the hospital is the repository of the best resources available to medical care, it would be a waste of time and energy to use those resources in other activities. Consequently, primary care is perceived as a separate program that should not interfere with the traditional functions of the hospital.
The combination of conceptual differences and lack of adequate information may lead to dangerous distortions regarding the meaning of primary care vis-à-vis the value of medical care in relation to the improvement of health.
Criticism of medical care is based on three main issues:
a) historically, most reductions in mortality rates have resulted from non-medical interventions, such as immunizations, sanitation and improvements in the standard of living;
b) many of the leading causes of death, including accidents, violence, chronic diseases and cardiovascular conditions, are closely related to environmental risks, lifestyles and personal habits; and
c) excessive confidence in the curative power of medicine has at times led to the overuse of services with minimal benefit or proven iatrogenic effects.
However, there is no doubt that the expansion of coverage to the entire population cannot be limited to offering basic health services to the poorest sectors while limitations in access to comprehensive services of undeniable value in the care of disease are perpetuated.
It is possible that these and other questions about the best way to organize health services do not have a single valid answer under the varied circumstances of social and economic development in different countries. What does seem to command consensus is the need to identify and define priority areas for health services research.
Risk approach in the context of health services research
The risk approach in maternal and child care is a concrete field for health services research. It begins with a characterization of the three major components of the planning and service delivery processes: health needs and demands; the scientific and technological system; and the infrastructure of health services.
