For readers of this journal, it is no surprise that primary care has a long history of innovation both in the United States and elsewhere. In recent years, primary care has received increased attention worldwide, from the proliferation of interest in the concept of the medical home in the United States to the commemoration of the 30th anniversary of the Alma Ata Declaration in 2008 (American Academy of Family Physicians et al., 2007). This special edition of Journal of Ambulatory Care Management comprises a series of articles highlighting several innovative approaches to addressing primary care challenges in a variety of countries throughout the Americas.

The recent World Health Report 2008 summarized several steps necessary to revitalize a primary healthcare approach to health systems' strengthening, including (1) enhancing universal access to primary care, (2) reforming the way primary care services are organized and delivered, (3) integrating primary care with public health and public policy approaches to tackling the upstream determinants of health inequalities, and (4) strengthening leadership and oversight of health systems and services to make them more relevant and responsive to population needs (World Health Organization, 2008). Each of the articles responds to one or more of these priority areas.

Several articles assess innovations in enhancing access to primary care services. Ruiz Chiriboga evaluates Ecuador's experience in expanding access to primary care through a national health insurance approach to providing free maternal and child care, finding that it was effective in increasing use of primary care services and effective in improving some outcomes, such as neonatal mortality. Bascolo and Yavich analyze the ways local governance structures helped determine variations in the effectiveness of the province of Buenos Aires' plan to provide health insurance to its citizens.

In terms of organizational reforms, Rubinstein and colleagues find that the use of pay-for-performance approaches can be effective in improving some aspects of primary care delivery but are careful to discuss how "generic" performance indicators adapted from countries such as the United Kingdom may need to be adapted to local contexts of their Buenos Aires-based health plan. Guanais and Macinko assess how the expansion of a community-based primary care program in Brazil may have altered hospital utilization patterns by reducing a number of ambulatory care-sensitive hospitalizations. Puig et al. address the challenges of assessing the quality of ambulatory care from the user's perspective, especially in the context of a health system with multiple payers and providers in the public, private, and nonprofit sectors in Mexico.

In addressing governance in primary healthcare, Shimizu and colleagues discuss an innovative feature of primary care in Brazil: local health councils. Their study suggests that such councils can improve public accountability but are still limited in their ability to affect health policy at the local level. Solicitation of public opinion on the development of health policies is another way to help align primary care with population health needs. White and Nanan discuss the results of British Colombia's attempts to engage the public in discussing the purpose and scope of primary healthcare and in prioritizing areas for reform efforts. Finally, Macinko and colleagues review the evidence base for the effectiveness of primary healthcare on the health of populations living in low- and middle-income countries. They find that although the literature generally supports the contention that a strong primary healthcare approach enhances health outcomes, there is still considerable work to be done in systematically assessing experiences and building a more comprehensive evidence base on primary care and health outcomes.

Our intention for the issue is to provide a forum for facilitating international dialogue and exchange of experience on primary care organization, management, and effectiveness. Taken together, these articles show that primary care is alive and well in many countries of the Americas, and there are likely to be many additional experiences and lessons learned in other countries that have not been included here. Thus, this collection of articles should be viewed as the beginning of a process rather than a report on its conclusion.

We hope that the edition will help facilitate discussion and accelerate the exchange of information and practical tools to help strengthen primary care planning, practice, and policy in the United States and throughout the Americas. We encourage readers to reach out to contributors and begin to build this global primary care network. The many challenges faced by proponents of a primary care approach to strengthening health systems are more common than might first be imagined, and the diversity of ways to surmount such challenges provides a rich laboratory for innovation and cross-national learning.

James Macinko, PhD

Guest Editor

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