Reflection
The perspective of community health nursing
in Primary Health Care in Portugal*
A perspectiva da enfermagem comunitária na Atenção Básica em
Portugal
La perspectiva de la enfermería comunitaria en la Atención Básica en
Portugal
Maria Adriana Henriques1, Elisa Garcia2, Madalena Bacelar3
Abstract resumo Resumen
Portugal, in 2005, initiated to reconfigure Portugal, em 2005, iniciou uma reconfigu- En 2005, Portugal inició una reconfigura-
its health centers, an action referred to as ração dos centros de saúde que nomeou ción de los centros de salud a la que llamó
the reform of primary health care, with the como reforma da atenção básica, com os reforma de la atención básica, con los ob-
objective to improve accessibility, efficien- objectivos de melhorar a acessibilidade, jetivos de mejorar la accesibilidad, eficien-
cy, quality and the continuity of care, and a eficiência, a qualidade e a continuidade cia, calidad y continuidad de los cuidados
increase the satisfaction of the population dos cuidados e aumentar a satisfação dos y aumentar la satisfacción de los profesio-
and the professionals. The health center profissionais e cidadãos. Foram reorganiza- nales y ciudadanos. Fueron reorganizados
groups were reorganized and new types of dos os agrupamentos de centros de saúde los organigramas de centros de salud y se
units were created. Also, at the same time, e criadas novas tipologias de unidades de crearon nuevas tipologías de unidades de
the health care continuity process and the cuidados. Paralelamente foi desenvolvido atención. Paralelamente, fue desarrollado
national network for integrated continuous o processo de continuidade de cuidados el proceso de continuidad de atención y la
care were developed. The nursing inter- e a rede nacional de cuidados continua- red nacional de atención continuada inte-
ventions in the care provided to individu- dos integrados. As intervenções de enfer- grada. Las intervenciones de enfermería en
als, families, groups and communities, in magem nos cuidados a pessoas, famílias, la atención a personas, familias, grupos y
the current reform, are essential for suc- grupos e comunidades, na atual reforma, comunidades, según la actual reforma, son
cess. The first reports still indicate a few são fundamentais para o seu êxito. Os pri- fundamentales para su éxito. Los primeros
inefficiencies that the current reform pro- meiros relatórios apresentam ainda algu- informes determinan aún algunas inefi-
posed to systematically improve, affecting mas ineficiências que a actual reforma se ciencias que la actual reforma se propone
the quality of good practices, users’ well propõe melhorar de forma sistemática in- mejorar de forma sistemática, incidiendo
being, and workers’ satisfaction. cidindo na qualidade das boas práticas, no en la calidad de las buenas prácticas, en el
bem estar dos usuarios e a satisfação dos bienestar de los pacientes y en la satisfac-
profissionais. ción de los profesionales.
descriptors descritores descriptores
Community health nursing Enfermagem em saúde comunitária Enfermería en salud comunitaria
Primary Health Care Atenção Primária à Saúde Atención Primaria de Salud
Community Health Centers Centros Comunitários de Saúde Centros Comunitarios de Salud
* This article was presented as a roundtable entitled “Desafios Contemporâneos da Saúde Coletiva” at the 2º Simpósio Internacional de Políticas e Práticas
em Saúde Coletiva na perspecitva da Enfermagem - SINPESC, University of São Paulo School of Nursing, São Paulo, Oct 9-11. 2011. 1Registered Nurse.
PhD in Nursing. Master in Epidemiology. Professor and coordinator of the Community Health Nursing Department of the Nursing School of Lisbon. Lisbon,
2Registered Nurse. Specialist in Public Health Nursing. PhD student at the Health Sciences Institute. Professor and coordinator
of the Nursing School of Lisbon. Lisbon, 3Registered Nurse. Master in Nursing Sciences. Specialist in Public Health Nursing. Head
nurse at the Public Health Department of ARS Lisbon and Tejo Valley. Lisbon,
1782
Rev Esc Enferm USP Received: 10/14/2011 The perspective of community health/ Inglês
Português nursing in
2011; 45(Esp. 2):1782-7 Approved: 11/16/2011 Primary Health Care in Portugal
www.scielo.br/reeusp
www.ee.usp.br/reeusp/ Henriques MA, Garcia E, Bacelar M
, INTRODUCTION care resources. However, despite the change in the orga-
nizational structure, the healthcare practice of the first
generation HCs persisted throughout the years as a result
The Alma-Ata declaration, which emerged as a result of administrative and governmental models.
of the 1st International Conference of 1978, defined pri-
mary healthcare (PHC) as crucial to achieving a level of In the decades of the 1980s and 1990s, health policies
health in which a socially and economically productive were strongly influenced by the health promotion move-
life would be granted to everyone. This was the begin- ment advocated by the WHO and originating from the
ning of the Primary Health Care movement. Profession- Ottawa Charter of 1986 and others which stimulated the
als and institutions, governments and civil society orga- development of projects such as healthy cities and health
nizations, researchers and small organizations decided to promoting schools(5).
address the problems of inequities in healthcare(1). Since In 1990, the Law of Health Bases (law No. 48/90 of 24th
2005, the reform of primary health care in Portugal has august) valorized the importance of PHCs in the health-
been invigorated. care system. It was established that the healthcare system
First Generation Health Centers were created in Portu- must be structured upon PHCs, be situated within the
gal in 1971 and have developed through different stages communities and provide intense articulation between
in the last 40 years. At the time of their creation, Portugal the different healthcare levels.
presented very unfavorable socioeconomic indicators in From 1996 to 1999 a goal-driven health strategy was
the context of Western Europe. In this initial phase, the introduced. This strategy identified 27 areas of interven-
activities of the Health Centers (HCs) were associated with tion, ranging from active life to aging, from youth school
what was considered to be public health at health to depression in the elderly, including
that time – population vaccine coverage, domains such as access to healthcare servic-
surveillance of pregnant women and chil- es, management of resources and medica-
dren, school health, and activities of health ... despite the change tion, and European cooperation. Goals of 5
authorities concerned with epidemiologic in the organizational to 10 years were defined for these domains
control and surveillance. structure, the and guidance for achievement of this was
In this context, community health nurs- healthcare practice provided(5).
ing focused on disease prevention and of the first generation In 1999, the Third Generation HCs
health promotion within vulnerable groups HCs persisted emerged based on field experiences and on
(mothers, children, youths, and families at throughout the a philosophy of group practices. These HCs
risk of poverty). Nursing activities were con- years as a result of were user and community oriented, had
ducted in teams and were articulated with administrative and small multi-professional units, and were
groups of specialized physicians, pediatrics,
gynecologists and public health doctors, as
governmental models. organized by lists of users from small geo-
graphical areas situated in the community.
well as integrated in vaccination campaigns Although they were formally defined, they
and practices of health promotion essen- never actually worked but served as a base
tially for women and children(3). Two styles of practice for the reform of primary healthcare that started in 2005
coexisted: one based on community health, which aimed and aimed to reorganize the HCs.
to promote health and prevent disease, and another, a
predominantly curative practice, which tried to respond Community health nursing, centered on working with
to the demands of the people at the clinics of the Social- families and groups in the community, was strengthened
Medical Services and at the Social Security Services pro- with the Munich Declaration of 2006(6). This declaration
viding consultations, treatment and domicile visits to aimed to identify specific actions in order to support the
administer medication and nursing treatment. This dis- capacity of the nurses to contribute to healthcare and the
tinction in healthcare practices perpetuated, from the or- quality of life of people seeking care. Family health nurs-
ganizational point of view, until 1982(4). ing became identified and valorized in the public health
and primary healthcare context.
A major change started to be designed with the cre-
ation of the National Health Service in 1979. This service At that time, community health nursing received a
was proposed to be universal and progressively free, and legacy that demanded deep changes in the level of prepa-
was established in the new Federal Constitution, which ration of the family nurses. These nurses would have to
fostered hope for better healthcare for everyone and the know how to smoothly coordinate and articulate knowl-
idea of progress and social justice(3). In 1983 the HCs as- edge from different work instruments – originating from
similated curative healthcare and originated the Integrat- public health, clinical practice and primary healthcare -
ed HCs, called Second Generation HCs(3). This process led which were developed in different ways, with mismatched
to the creation of the General Direction of Primary Health- times and rhythms(7). This new perspective demanded the
care and to a better formal rationalization of the health- development of a view regarding what public health and
1783
The perspective of community health nursing in Rev Esc Enferm USP
Primary Health Care in Portugal 2011; 45(Esp. 2):1782-7
Henriques MA, Garcia E, Bacelar M www.ee.usp.br/reeusp/
The perspective of community health nursing
in Primary Health Care in Portugal*
A perspectiva da enfermagem comunitária na Atenção Básica em
Portugal
La perspectiva de la enfermería comunitaria en la Atención Básica en
Portugal
Maria Adriana Henriques1, Elisa Garcia2, Madalena Bacelar3
Abstract resumo Resumen
Portugal, in 2005, initiated to reconfigure Portugal, em 2005, iniciou uma reconfigu- En 2005, Portugal inició una reconfigura-
its health centers, an action referred to as ração dos centros de saúde que nomeou ción de los centros de salud a la que llamó
the reform of primary health care, with the como reforma da atenção básica, com os reforma de la atención básica, con los ob-
objective to improve accessibility, efficien- objectivos de melhorar a acessibilidade, jetivos de mejorar la accesibilidad, eficien-
cy, quality and the continuity of care, and a eficiência, a qualidade e a continuidade cia, calidad y continuidad de los cuidados
increase the satisfaction of the population dos cuidados e aumentar a satisfação dos y aumentar la satisfacción de los profesio-
and the professionals. The health center profissionais e cidadãos. Foram reorganiza- nales y ciudadanos. Fueron reorganizados
groups were reorganized and new types of dos os agrupamentos de centros de saúde los organigramas de centros de salud y se
units were created. Also, at the same time, e criadas novas tipologias de unidades de crearon nuevas tipologías de unidades de
the health care continuity process and the cuidados. Paralelamente foi desenvolvido atención. Paralelamente, fue desarrollado
national network for integrated continuous o processo de continuidade de cuidados el proceso de continuidad de atención y la
care were developed. The nursing inter- e a rede nacional de cuidados continua- red nacional de atención continuada inte-
ventions in the care provided to individu- dos integrados. As intervenções de enfer- grada. Las intervenciones de enfermería en
als, families, groups and communities, in magem nos cuidados a pessoas, famílias, la atención a personas, familias, grupos y
the current reform, are essential for suc- grupos e comunidades, na atual reforma, comunidades, según la actual reforma, son
cess. The first reports still indicate a few são fundamentais para o seu êxito. Os pri- fundamentales para su éxito. Los primeros
inefficiencies that the current reform pro- meiros relatórios apresentam ainda algu- informes determinan aún algunas inefi-
posed to systematically improve, affecting mas ineficiências que a actual reforma se ciencias que la actual reforma se propone
the quality of good practices, users’ well propõe melhorar de forma sistemática in- mejorar de forma sistemática, incidiendo
being, and workers’ satisfaction. cidindo na qualidade das boas práticas, no en la calidad de las buenas prácticas, en el
bem estar dos usuarios e a satisfação dos bienestar de los pacientes y en la satisfac-
profissionais. ción de los profesionales.
descriptors descritores descriptores
Community health nursing Enfermagem em saúde comunitária Enfermería en salud comunitaria
Primary Health Care Atenção Primária à Saúde Atención Primaria de Salud
Community Health Centers Centros Comunitários de Saúde Centros Comunitarios de Salud
* This article was presented as a roundtable entitled “Desafios Contemporâneos da Saúde Coletiva” at the 2º Simpósio Internacional de Políticas e Práticas
em Saúde Coletiva na perspecitva da Enfermagem - SINPESC, University of São Paulo School of Nursing, São Paulo, Oct 9-11. 2011. 1Registered Nurse.
PhD in Nursing. Master in Epidemiology. Professor and coordinator of the Community Health Nursing Department of the Nursing School of Lisbon. Lisbon,
2Registered Nurse. Specialist in Public Health Nursing. PhD student at the Health Sciences Institute. Professor and coordinator
of the Nursing School of Lisbon. Lisbon, 3Registered Nurse. Master in Nursing Sciences. Specialist in Public Health Nursing. Head
nurse at the Public Health Department of ARS Lisbon and Tejo Valley. Lisbon,
1782
Rev Esc Enferm USP Received: 10/14/2011 The perspective of community health/ Inglês
Português nursing in
2011; 45(Esp. 2):1782-7 Approved: 11/16/2011 Primary Health Care in Portugal
www.scielo.br/reeusp
www.ee.usp.br/reeusp/ Henriques MA, Garcia E, Bacelar M
, INTRODUCTION care resources. However, despite the change in the orga-
nizational structure, the healthcare practice of the first
generation HCs persisted throughout the years as a result
The Alma-Ata declaration, which emerged as a result of administrative and governmental models.
of the 1st International Conference of 1978, defined pri-
mary healthcare (PHC) as crucial to achieving a level of In the decades of the 1980s and 1990s, health policies
health in which a socially and economically productive were strongly influenced by the health promotion move-
life would be granted to everyone. This was the begin- ment advocated by the WHO and originating from the
ning of the Primary Health Care movement. Profession- Ottawa Charter of 1986 and others which stimulated the
als and institutions, governments and civil society orga- development of projects such as healthy cities and health
nizations, researchers and small organizations decided to promoting schools(5).
address the problems of inequities in healthcare(1). Since In 1990, the Law of Health Bases (law No. 48/90 of 24th
2005, the reform of primary health care in Portugal has august) valorized the importance of PHCs in the health-
been invigorated. care system. It was established that the healthcare system
First Generation Health Centers were created in Portu- must be structured upon PHCs, be situated within the
gal in 1971 and have developed through different stages communities and provide intense articulation between
in the last 40 years. At the time of their creation, Portugal the different healthcare levels.
presented very unfavorable socioeconomic indicators in From 1996 to 1999 a goal-driven health strategy was
the context of Western Europe. In this initial phase, the introduced. This strategy identified 27 areas of interven-
activities of the Health Centers (HCs) were associated with tion, ranging from active life to aging, from youth school
what was considered to be public health at health to depression in the elderly, including
that time – population vaccine coverage, domains such as access to healthcare servic-
surveillance of pregnant women and chil- es, management of resources and medica-
dren, school health, and activities of health ... despite the change tion, and European cooperation. Goals of 5
authorities concerned with epidemiologic in the organizational to 10 years were defined for these domains
control and surveillance. structure, the and guidance for achievement of this was
In this context, community health nurs- healthcare practice provided(5).
ing focused on disease prevention and of the first generation In 1999, the Third Generation HCs
health promotion within vulnerable groups HCs persisted emerged based on field experiences and on
(mothers, children, youths, and families at throughout the a philosophy of group practices. These HCs
risk of poverty). Nursing activities were con- years as a result of were user and community oriented, had
ducted in teams and were articulated with administrative and small multi-professional units, and were
groups of specialized physicians, pediatrics,
gynecologists and public health doctors, as
governmental models. organized by lists of users from small geo-
graphical areas situated in the community.
well as integrated in vaccination campaigns Although they were formally defined, they
and practices of health promotion essen- never actually worked but served as a base
tially for women and children(3). Two styles of practice for the reform of primary healthcare that started in 2005
coexisted: one based on community health, which aimed and aimed to reorganize the HCs.
to promote health and prevent disease, and another, a
predominantly curative practice, which tried to respond Community health nursing, centered on working with
to the demands of the people at the clinics of the Social- families and groups in the community, was strengthened
Medical Services and at the Social Security Services pro- with the Munich Declaration of 2006(6). This declaration
viding consultations, treatment and domicile visits to aimed to identify specific actions in order to support the
administer medication and nursing treatment. This dis- capacity of the nurses to contribute to healthcare and the
tinction in healthcare practices perpetuated, from the or- quality of life of people seeking care. Family health nurs-
ganizational point of view, until 1982(4). ing became identified and valorized in the public health
and primary healthcare context.
A major change started to be designed with the cre-
ation of the National Health Service in 1979. This service At that time, community health nursing received a
was proposed to be universal and progressively free, and legacy that demanded deep changes in the level of prepa-
was established in the new Federal Constitution, which ration of the family nurses. These nurses would have to
fostered hope for better healthcare for everyone and the know how to smoothly coordinate and articulate knowl-
idea of progress and social justice(3). In 1983 the HCs as- edge from different work instruments – originating from
similated curative healthcare and originated the Integrat- public health, clinical practice and primary healthcare -
ed HCs, called Second Generation HCs(3). This process led which were developed in different ways, with mismatched
to the creation of the General Direction of Primary Health- times and rhythms(7). This new perspective demanded the
care and to a better formal rationalization of the health- development of a view regarding what public health and
1783
The perspective of community health nursing in Rev Esc Enferm USP
Primary Health Care in Portugal 2011; 45(Esp. 2):1782-7
Henriques MA, Garcia E, Bacelar M www.ee.usp.br/reeusp/
