ABSTRACT

The COVID-19 pandemic reinforced the need for global efforts to grant universal health coverage and access, which imposes management challenges for Primary Health Care (PHC). This study aimed to develop and apply an instrument to assess the PHC Units’ responsiveness to COVID-19, based on co-production efforts between university researchers and PHC technical teams. The instrument composed of two modules, included identification, operating hours, workforce, work process, structure, equipment, furniture, supplies, Personal Protection Equipment (PPE), Symptomatic Respiratory Patient (SRP) examinations and follow-up, information, surveillance, integration, communication, and management. All the 165 PHC Units in Brasília were invited to complete the instrument. Main results: there was physical structure adaptation (adequate configuration of waiting rooms, internal and external spaces allowing safe distance); provision of PPE and COVID-19 tests; active search for SRP/COVID-19 suspects by phone, mobile or home visits; monitoring flows of patient transfer and telehealth implementation. In conclusion, the PHC Units reorganized their services to meet the demands of the pandemic context. Providing information about structure and responsiveness of PHC Units may subside health systems for planning and decision-making at different levels of management, which is crucial to determine strategies to empower and reinforce PHC responsivity in situations of pandemics and other calamities.

KEYWORDS
COVID-19; Primary Health Care; Structure of services; Evaluation study; Health services research

Introduction

Health systems in high and low-middle income countries have faced the challenge of dealing with the existing high prevalence of chronic non-communicable diseases, along with pandemics that represent a global risk. Spread worldwide, COVID-19 has reinforced the need for joint efforts aimed at strengthening Universal Health Coverage (UHC) and access to health services, which imposes management challenges to Primary Health Care (PHC) Units<sup>11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...

2 Lahariya C. Health & wellness centers to strengthen primary health care in India: Concept, progress and ways forward. The Indian J. Pediat. 2020 [access on 2021 Feb 20]; 87(11):916-29. Available at: https://link.springer.com/article/10.1007/s12098-020-03359-z.
https://link.springer.com/article/10.100...

3 Li X, Krumholz HM, Yip W, et al. Quality of primary health care in China: Challenges and recommendations. The Lancet. 2020 [access on 2021 Feb 6]; 395(10239):1802-12. Available at: https://www.sciencedirect.com/science/article/pii/S0140673620301227.
https://www.sciencedirect.com/science/ar... -44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...</sup> . Investing in PHC is a priority for improving access to health.

The COVID-19 pandemic highlights the role of PHC as the preferred entrance door integrated into a wider healthcare network within the scope of the Brazilian Unified Health System (SUS). Similarly, other countries, such as the United Kingdom, Australia, and Iceland, have PHC as the preferred gateway and filter for more complex levels of care^{55 Prado NMBL, Rossi TRA, Chaves SCL, et al. The international response of primary health care to Covid-19: Document analysis in selected countries. Cad. Saúde Pública. 2020 [access on 2021 Nov 21]; 36(12):e00183820. Available at: https://www.scielo.br/j/csp/a/7ws7tVbWLS7LYk559MBJfLL/?format=html&lang=e.
https://www.scielo.br/j/csp/a/7ws7tVbWLS...} . Considering that primary care is where most healthcare takes place, it is essential to find ways to best sustain its services to provide the necessary responses to pandemics^{66 Huston P, Huston JC, Grant R, et al. COVID-19 and primary care in six countries. BJGP Open. 2020 [access on 2022 Apr 27]; 4(4):bjgpopen20X101128. Available at: https://bjgpopen.org/content/4/4/bjgpopen20X101128?utm_source=trendmd&utm_medium=cpc&utm_campaign=BJGP_Open.
https://bjgpopen.org/content/4/4/bjgpope...} .

The availability of tools may subsidize health managers and direct the investments needed to allow the implementation of appropriate strategies towards improving PHC. The complexity of PHC evaluation is recognized and the importance of information production before defining interventions towards PHC services^{77 Cubas MR, Faoro NT, Moysés ST, et al. Avaliação da Atenção Primária à Saúde: validação de instrumento para análise de desempenho dos serviços. Saúde debate. 2017 [access on 2022 Apr 20]; 41(113):471-85. Available at: https://doi.org/10.1590/0103-1104201711310.
https://doi.org/10.1590/0103-11042017113...} is highlighted. To tackle the challenges imposed by local reality, especially in the context of extreme situations as the pandemic scenario, it is even more relevant to have elements to optimize quick responses. That way, constructing instruments based on existing experiences, but also dialoguing with local reality, may be innovative and useful to health services.

Evaluating health services from the perspective of the concept of responsiveness may bring the opportunity to guide reorientation of practices with greater chance to have adherence and commitment and consequently better respond to the actual needs. Responsiveness is a measure of how health systems address expectations of people in a legitime way^{88 Mirzoev T, Kane S. What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework. BMJ Glob Health. 2017 [access on 2022 Apr 20]; 2(4):e000486. Available at: https://gh.bmj.com/content/2/4/e000486.abstract.
https://gh.bmj.com/content/2/4/e000486.a...} .

The aim of this study was the development and application of an instrument to analyze the structures and responsiveness of PHC Units to COVID-19, in order to identify resource availability and gaps, enabling the necessary adjustments.

Material and methods

Background

An instrument was developed as part of the activities related to the ongoing PHC Qualification Program (QualisAPS), implemented in Brasília, Federal District (DF), the capital of Brazil. This PHC is based on the Family Health Strategy (FHS), as defined by the local government directive since 2017^{99 Federal Distrito. Portaria nº 77, de 14 de fevereiro de 2017. Estabelece a Política de Atenção Primária à Saúde do Distrito Federal. Diário Oficial do Distrito Federal. 2017 Feb 14. [access on 2021 Feb 6]. Available at: http://www.sinj.df.gov.br/sinj/Norma/b41d856d8d554d4b95431cdd9ee00521/ses_prt_77_2017.html.
http://www.sinj.df.gov.br/sinj/Norma/b41...} . The QualisAPS Program, implemented in 2019, aims to qualify management and health care to improve the PHC services provided. It involves the use of innovative methods for coproduction and the development of participatory assessment for healthcare teams, scientific dissemination, and diffusion and incorporation of knowledge.

The structure is an important component of health systems. In this study, structure is defined as the physical, technical, and organizational aspects considered essential for the quality of health service provision^{1010 Scholz S, Ngoli B, Flessa S. Rapid assessment of infrastructure of primary care facilities - a relevant instrument for health care systems management. BMC Health Servic Research. 2015 [access on 2022 Apr 20]; 15(1):1-10. Available at: https://link.springer.com/article/10.1186/s12913-015-0838-8.
https://link.springer.com/article/10.118...} .

Methodology for instrument development

The instrument was developed according to the general guidelines for PHC services, in addition to the Contingency plans and Technical Notes that dealt specifically with adaptations and reorganization of PHC to tackle the COVID-19 pandemic at the local level.

Initially, a literature review was performed using the documentary analysis method. The review included norms and technical documents from the Ministry of Health and the local Health Secretariat, such as guides, manuals, and guidelines for clinical and organizational support of PHC, elaborated in the context of the pandemic (box 1).

From the document analysis, we identified and developed items to measure indicators for each of the structural axes of PHC during the COVID-19 pandemic: functioning during the COVID-19 pandemic, workforce, organization, and work processes of health teams. Thus physical structure, equipment, furniture and supplies; Personal Protective Equipment (PPE) and collective protection measures; follow-up of the patients and exams; and information, surveillance, integration, communication, and management of health services were considered.

The following step included a panel of experts composed of a group of specialists in PHC from the University of Brasília (QualisAPS members) and from Federal University of São Paulo - UNIFESP (invited member), and health professionals from the local of Health Secretariat. The group reviewed all items of the instrument for criteria of clarity, simplicity, objectivity, and technical and contextual adequacy and provided feedback on necessary items on each structure axis.

The expert panel technique has been utilized in a great variety of health research studies^{1111 Hogg W, Rowan M, Russel G, et al. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care. 2008 [access on 2022 Apr 22]; 20(5):308-13. Available at: https://academic.oup.com/intqhc/article/20/5/308/1793755?login=false.
https://academic.oup.com/intqhc/article/... ,1212 Pinheiro JQ, Farias TM, Abe-Lima JY. Painel de Especialistas e Estratégia Multimétodos: Reflexões, Exemplos, Perspectivas. Psico. 2013 [access on 2022 Apr 27]; 44(2). Available at: https://revistaseletronicas.pucrs.br/index.php/revistapsico/article/view/11216.
https://revistaseletronicas.pucrs.br/ind...} . Its implementation in this study was based on the QualisAPS Program postulate that the best strategy to encourage the use of evaluation results is to build any instrument in the context in which it will be applied. Also, besides taking into consideration the literature reports, it is relevant to consider experiences, interests, and problems detected and seen as significant by health managers and professionals<sup>1313 Dennis J-L, Champagne F. Análise da Implantação. In: Hartz MA, organizadores. Avaliação em Saúde: dos modelos conceituais à prática na análise da implantação de programas. Rio de Janeiro: Fiocruz; 1997. p. 49-88. [access on 2022 Apr 27]. Available at: https://static.scielo.org/scielobooks/3zcft/pdf/hartz-8585676361.pdf.
https://static.scielo.org/scielobooks/3z...

14 Patton MQ. Utilization-focused evaluation: process and premises. Utilization focused evaluation: the news century text. 1997 [access on 2022 Apr 27]; (3):371-85. Available at: https://www.betterevaluation.org/en/resource/guide/UFE_4th_edn.
https://www.betterevaluation.org/en/reso... -1515 Patton ERL, Labossière F. L’évaluation axée sur l’utilisation. In: Ridde V, Dagenais C. Approches et pratiques en évaluation de programme. Montréal: Les Presses de l’Université de Montréal; 2012. p. 145-160. [access on 2022 Apr 27]. Available at: https://books.openedition.org/pum/5959.
https://books.openedition.org/pum/5959...</sup> , in a co-production perspective<sup>1616 Traynor R, Dobbins M, Decorby K. Challenges of partnership research: insights from a collaborative partnership in evidence-informed public health decision making. Evid Policy A J Res Debate Pract. 2015 [access on 2022 Apr 27]; 11(1):99-109. Available at: https://eric.ed.gov/?id=EJ1131923.
https://eric.ed.gov/?id=EJ1131923...

17 Filipe A, Renedo A, Marston C. The co-production of what? Knowledge, values, and social relations in health care. PLoS Biol. 2017 [access on 2022 Apr 28]; 15(5):e2001403. Available at: https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.2001403.
https://journals.plos.org/plosbiology/ar... -1818 Langley J, Wolstenholme D, Cooke J. ‘Collective making’ as knowledge mobilisation: the contribution of participatory design in the co-creation of knowledge in healthcare. BMC Health Serv Res. 2018 [access on 2022 Apr 27]; 18(1):1-10. Available at: https://link.springer.com/article/10.1186/s12913-018-3397-y.
https://link.springer.com/article/10.118...</sup> .

METHODOLOGY FOR INSTRUMENT APPLICATION

We applied the software Research Eletronic Data Capture (REDCap), an open access platform, for data collection, developed by the Vanderbilt University, Tennessee, USA. REDCap allows storing and managing research and databases, as well as creating data collection instruments, managing reports, among other functionalities^{1919 Harris PA, Taylor R, Payne J, et al. Research electronic data capture (REDCap) a metadata-driven methodology and workflow process for providing translational research informatics support. J. biomed. info. 2009 [access on 2022 Apr 27]; 42(2):377-381. Available at: https://www.sciencedirect.com/science/article/pii/S1532046408001226.
https://www.sciencedirect.com/science/ar... ,2020 Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. Journal of biomedical informatics. 2019 [access on 2022 Apr 28]; (95):103208. Available at: https://www.sciencedirect.com/science/article/pii/S1532046419301261.
https://www.sciencedirect.com/science/ar...} .

Before application, the instrument’s axes were divided into two modules to be applied through telephone interviews and through self-completion, respectively. The axes that included information readily available by the PHC Unit managers were surveyed by telephone interviews. The axes that required searches from internal reports and information systems were allocated to the self-completion link and sent when the telephone interview was concluded.

At this stage, the instrument was pretested by health managers of two PHC Units in Brasília. The issues raised, mainly related to clarity and language adequacy, were modified. The average time for the instrument application was identified as 45 minutes for the telephone interview and 60 minutes for the self-completion instrument. The instrument was developed in June-July 2020, period of the first pandemic wave; data collection occurred from August 2020 to January 2021, before the second pandemic wave in Brasília, which happened in March 2021.

The units of analysis are the PHC Units of Brasília. The potential respondents are the Unit´s managers who were first contacted by telephone. After the arrangements for the interview, an email was sent to reinforce the information provided on the phone call. The informed consent form was sent by email and signed before the telephone interview date. This study was approved by the Ethical Committee from the Faculty of Health Sciences of University of Brasília (CAAE no.29640120.6.0000.0030).

Results and discussion

Instrument structure

The final version of the instrument designed to analyze the structure and responsiveness of PHC Units to COVID-19 was composed of 11 thematic axes, with a total of 127 items, distributed in two modules. The telephone-based module consists of 60 items distributed between axis 1 (respondent identification), axis 2 (identification of PHC Unit), axis 5 (organization and work process), axis 6 (structure), axis 8 (PPE), and axis 11 (management) (figure 1). The self-completion module is composed of 67 items organized in axis 3 (functioning of PHC Unit during the COVID-19 pandemic), axis 4 (workforce), axis 7 (equipment, furniture and supplies), axis 9 (patient follow-up and examinations), and axis 10 (information, surveillance, integration, and communication) (figure 2).

The instrument was planned to encompass the PHC’s attributions, and its different dimensions of organization and functioning to provide comprehensive care. Therefore, the evaluation included identification, functioning hours, workforce, work process, structure, equipment, furniture, supplies, PPE, Symptomatic Respiratory Patient (SRP)/COVID-19 suspects’ examinations and follow-up, information, surveillance, integration, communication, and management.

Results of instrument application

All 165 PHC Units functioning in Brasília, DF completed the telephone-based instrument, whereas 159 filled the self-completion module, from August 2020 to January 2021. Application of the instrument to evaluate the structure and responsiveness was essential to describe the work process, structure and inputs’ availability. Selected variables are presented in tables 1 and 2. The instrument covered other aspects related to the care of COVID-19 and Symptomatic Respiratory Patients (SRP), in addition to the ones presented in the following tables.

Table 1 shows favorable adaptations in the work process within the PHC Units, as the majority of them (over 88%) assigned a health worker to identify SRP/COVID-19 suspects at the entrance, immediately performing risk classification and directing them to appropriate care. The structural configurations of PHC Units in Brasília also demonstrated availability of adequate external space for SRP/COVID-19 suspects to wait for assistance in almost 82% of them. On the other hand, in only 60% of the PHC Units there is internal space reserved only for those patients. Ventilated consultations offices dedicated exclusively to SRP/COVID-19 suspect cases were available in 81% of Units, but just 68% of the offices had a sink, water, and soap.

Results showed adherence to important aspects within the scope of PHC services, including actions to avoid the transmission of COVID-19, such as social distance, separation of the areas of health services offered to SRP and other patients, the use of masks, frequent hand and surface hygiene, as pointed by other studies^{2121 Garg S, Basu S, Rustagi R, et al. Primary health care facility preparedness for outpatient service provision during the COVID-19 pandemic in India: Cross-sectional study. JMIR Public Health and Surv. 2020 [access on 2022 Apr 27]; 6(2):e19927. Available at: https://publichealth.jmir.org/2020/2/e19927/.
https://publichealth.jmir.org/2020/2/e19... ,2222 Hussain I, Majeed A, Imran I, et al. Knowledge, attitude, and practices toward COVID-19 in primary healthcare providers: A cross-sectional study from three tertiary care hospitals of Peshawar, Pakistan. J. Comm. Health. 2020 [access on 2022 Apr 28]; 46(3):441-49. Available at: https://link.springer.com/article/10.1007/s10900-020-00879-9.
https://link.springer.com/article/10.100...} . Recommendations include attending the SRP outside and in a ventilated area, the distance between patients and professionals, the use of physical barriers to maintain the distance, and changes in flows^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...} .

Most of the studied PHC Units reported to have PFF2, N95 and disposable surgical masks available for professionals, and 66% declared to offer surgical masks for SRP/COVID-19 suspects who attended the Unit, although the availability may vary throughout the month and among Units. Running out of PPE has been a great concern worldwide; shortages of visors, gowns, and facemasks mainly in care homes, community health facilities, and general practices were reported in the United Kingdom^{2323 Hoernke K, Djellouli N, Andrews L, et al. Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: A rapid qualitative appraisal. BMJ Open. 2021 [access on 2021 Feb 27]; 11(1):e046199. Available at: https://bmjopen.bmj.com/content/11/1/e046199.abstract.
https://bmjopen.bmj.com/content/11/1/e04...} . In Australia, some of the greatest concerns regarding teamwork and patient safety are related to the lack of resources, such as PPE^{2424 Kippen R, OSullivan B, Hickson H, et al. National survey of COVID-19 challenges, responses and effects in Australian general practice. Aust J Gen Pract. 2020 [access on 2021 Dec 12]; 49(11):745-51. Available at: https://search.informit.org/doi/abs/10.3316/INFORMIT.553734658477640.
https://search.informit.org/doi/abs/10.3...} . The availability of PPE, its use, and measures to minimize the transmission of COVID-19 are necessary to ensure safe working conditions and protect workers, as well as the population, by reducing the dissemination sources of COVID-19^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} . A global challenge was the availability of PPE: high-income countries have rapidly guaranteed their own internal PPE supply, causing a shortage for low-and middle-income countries dependent on external supply chains side by side to a preferential allocation to hospitals, at the expense of PHC points^{2525 Salman R, Allen LN, Stigler FL, et al. Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide. Euro. J. General Pract. 2020 [access on 2021 Dec 12]; 26(1):129-33. Available at: https://www.tandfonline.com/doi/full/10.1080/13814788.2020.1820479.
https://www.tandfonline.com/doi/full/10....} . Over 90% of the Family Health Teams conduct active search for new SRP/COVID-19 suspect cases. The majority of these contacts (88%) were done by telephone or mobile phone.

Our results show that the reorganization necessary to ensure safe and quality care in the face of structural limitations seems to meet the requirements according to the COVID-19 epidemic. In the Brazilian context, Sarti et al.^{2626 Sarti TD, Lazarini WS, Fontenelle LF, et al. What is the role of Primary Health Care in the COVID-19 pandemic?. Epid. Serv. Saúde. 2020 [access on 2022 Apr 28]; 29(2):e2020166. Available at: https://www.scielo.br/j/ress/a/SYhPKcN7f8znKV9r93cpF7w/?lang=en.
https://www.scielo.br/j/ress/a/SYhPKcN7f...} cite, among the specific strategies and actions to face the pandemic, the presence of trained health professionals; adequate physical space to handle suspected cases of COVID-19; diagnostic tests in sufficient quantity; structure for requesting complementary exams and diagnostic support. Equally important are well-defined flows and protocols for accessing health services at different levels of healthcare; epidemiological surveillance; adequate and sufficient personal protective equipment for healthcare professionals and symptomatic individuals^{2626 Sarti TD, Lazarini WS, Fontenelle LF, et al. What is the role of Primary Health Care in the COVID-19 pandemic?. Epid. Serv. Saúde. 2020 [access on 2022 Apr 28]; 29(2):e2020166. Available at: https://www.scielo.br/j/ress/a/SYhPKcN7f8znKV9r93cpF7w/?lang=en.
https://www.scielo.br/j/ress/a/SYhPKcN7f...} .

Regarding COVID-19 tests, at the time of data collection, rapid (antibody test) and swab (RT-PCR tests) were available in almost 65% and 75% of the Units, respectively. The accessibility of the rapid test was not ideal (65%) considering that the distribution of serological tests for COVID-19 was among one of the federal actions planned to occur to support and strengthen the fight against COVID-19^{2727 Harzheim E, Martins C, Wollmann L, et al. Federal actions to support and strengthen local efforts to combat COVID-19: Primary Health Care (PHC) in the driver’s seat. Ciênc. Saúde Colet. 2020 [access on 2022 Apr 28]; (25):2493-97. Available at: https://www.scielosp.org/article/csc/2020.v25suppl1/2493-2497/en/.
https://www.scielosp.org/article/csc/202...} . The vast majority of PHC Units included in this survey had a complete emergency cart, with life support devices/medication in case of need for assistance to a critical SRP. Coping with COVID-19 requires logistical and operational equipment and materials. The monitoring of patients and tests, home care visits, O2 supply, and flows for laboratory tests is part of the PHC’s role in confronting COVID-19. Depending on the severity of the cases, the supply of O2 is important, and the continuity of patient care must take place in an integrated manner in PHC through efficient communication channels and flows^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} .

A recent study analyzed Primary Care provision in the context of the pandemic in six high income countries (Australia, New Zealand, Canada, Netherlands, UK, US) and reported that the lockdown severely reduced access and continuity of services in non-COVID-19 conditions, as managing the pandemic became a priority; in some ways, this limitation can be mitigated by telehealth support^{66 Huston P, Huston JC, Grant R, et al. COVID-19 and primary care in six countries. BJGP Open. 2020 [access on 2022 Apr 27]; 4(4):bjgpopen20X101128. Available at: https://bjgpopen.org/content/4/4/bjgpopen20X101128?utm_source=trendmd&utm_medium=cpc&utm_campaign=BJGP_Open.
https://bjgpopen.org/content/4/4/bjgpope...} . In the present study, out of the 159 PHC Units participants of the self-completion module, 57.2% reported to offer telehealth support. The professionals mostly involved in this service were physicians (39.6%), nurses (36.5%), community health workers (31.4%), and nurse technicians (22.6%). Teleconsultation is a strategy widely used elsewhere in the COVID-19 context^{66 Huston P, Huston JC, Grant R, et al. COVID-19 and primary care in six countries. BJGP Open. 2020 [access on 2022 Apr 27]; 4(4):bjgpopen20X101128. Available at: https://bjgpopen.org/content/4/4/bjgpopen20X101128?utm_source=trendmd&utm_medium=cpc&utm_campaign=BJGP_Open.
https://bjgpopen.org/content/4/4/bjgpope...} , but hampered in the present study (57.2%) because not all PHC Units have proper access to telephone and the internet. Regarding the availability of communication equipment, more than 40% of the PHC Units evaluated reported to have insufficient telephone equipment and computer network for the teams (data not shown). In Brazil, the Telehealth Program (Programa Telessaúde) was implemented in 2011 within the scope of the SUS, and could be an important tool in the fight against COVID-19^{2727 Harzheim E, Martins C, Wollmann L, et al. Federal actions to support and strengthen local efforts to combat COVID-19: Primary Health Care (PHC) in the driver’s seat. Ciênc. Saúde Colet. 2020 [access on 2022 Apr 28]; (25):2493-97. Available at: https://www.scielosp.org/article/csc/2020.v25suppl1/2493-2497/en/.
https://www.scielosp.org/article/csc/202... ,2828 Souza CDFD, Gois-Santos VTD, Correia DS, et al. The need to strengthen Primary Health Care in Brazil in the context of the COVID-19 pandemic. Braz. research. 2020 [access on 2022 Apr 28]; (34):e047. Available at: https://www.scielo.br/j/bor/a/FWF6mZvzvSByh9VBxTD4wCd/abstract/?lang=en.
https://www.scielo.br/j/bor/a/FWF6mZvzvS...} .

Teleconsultation should be encouraged as it makes services accessible to distant populations^{22 Lahariya C. Health & wellness centers to strengthen primary health care in India: Concept, progress and ways forward. The Indian J. Pediat. 2020 [access on 2021 Feb 20]; 87(11):916-29. Available at: https://link.springer.com/article/10.1007/s12098-020-03359-z.
https://link.springer.com/article/10.100...} . However, PHC Units must incorporate the SRP screening and classification protocols to subsidize both telehealth actions and face-to-face activities in the PHC Units^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...} .

In addition to the flow of care and reorganization of the PHC Units, it is crucial to have a defined flow of referral of serious cases to other levels of care, by means of exclusive ambulances for transportation^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...} . It was reported in the present study that the flow of referral to secondary and hospital levels were established in more than 80% of the PHC Units assessed, of which 67% considered the service adequate to the needs of patients.

The great majority of respondents (97%) reported having notified suspected cases of COVID-19 in the appropriate information systems. It was also reported that the number of SRP consultations compared to the total number was monitored in 70.4% Units. The recording and the use of information systems for surveillance, supply planning, organizing the agenda, and development of intersectoral actions by staff in the territory are key steps for tackling the pandemic in the context of PHC^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} .

Especially when dealing with respiratory-transmitted agents, such as SARS-CoV-2, epidemiological surveillance strategies allow the identification and control of contacts and the reduction of new cases. As stated by Teixeira et al.^{2929 Teixeira MG, Medina MG, Costa MDCN, et al. Reorganization of primary health care for universal surveillance and containment of Covid-19. Epid. Serv. Saúde. 2020 [access on 2022 Apr 28]; 29(4):e2020494. Available at: https://www.scielosp.org/article/ress/2020.v29n4/e2020494/en/.
https://www.scielosp.org/article/ress/20...} , health and epidemiological surveillance teams must work in an integrated manner to correctly feed the surveillance system and carry out COVID-19 prevention actions, with guidance and support for the general population and vulnerable groups^{2929 Teixeira MG, Medina MG, Costa MDCN, et al. Reorganization of primary health care for universal surveillance and containment of Covid-19. Epid. Serv. Saúde. 2020 [access on 2022 Apr 28]; 29(4):e2020494. Available at: https://www.scielosp.org/article/ress/2020.v29n4/e2020494/en/.
https://www.scielosp.org/article/ress/20...} .

Despite the challenges mentioned, the monitoring of suspected cases of COVID-19 and working with priority care for patients who have respiratory symptoms were also strategies adopted by 91.8% of the Units to face the pandemic context. The use of these and other information and communication features such as social media and messaging applications has the potential to ensure attention to the enrolled population, to avoid discontinuity of treatment and worsening of diseases, and contributes to the reduction of access and social inequality barriers. COVID-19 mostly affects minorities and poor and vulnerable populations, due to its inequitable spread in areas of dense population with limited response capacity, due to poor access to health services and high prevalence of chronic conditions^{3030 Shadmi E, Chen Y, Dourado I, et al. Health equity and COVID-19: global perspective. Inter. J. Equity in Health. 2020 [access on 2021 Dec 12]; 19(1):1-16. Available at: https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01218-z.
https://equityhealthj.biomedcentral.com/...} .

The consequences of COVID-19 pandemic in the PHC services working process should be considered. While it is essential to reorganize PHC services to face the pandemics, it is also necessary to maintain the regular offer of other activities and actions^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202... ,2121 Garg S, Basu S, Rustagi R, et al. Primary health care facility preparedness for outpatient service provision during the COVID-19 pandemic in India: Cross-sectional study. JMIR Public Health and Surv. 2020 [access on 2022 Apr 27]; 6(2):e19927. Available at: https://publichealth.jmir.org/2020/2/e19927/.
https://publichealth.jmir.org/2020/2/e19...} . Services like renewal of prescriptions, attention to other acute and chronic diseases^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...} , monitoring of socially vulnerable populations and groups at risk, and regular vaccination activities ought to continue^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk... ,44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} . However, these actions must be organized in such a way to minimize the risk of transmission of COVID-19^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} . In the present study, from the total of 137 PHC Units where vaccination services were reported to continue regularly, 77% stated that these services were reorganized in order to guarantee the least possible contact among patients (COVID-19 vaccination was not available when we conducted this survey - it started in late January 2021). From the PHC Units where pharmaceutical assistance was offered (n=137), prescriptions with an extension of validity to 60 days, without the need for renewal, were accepted in the great majority (81%), in order to reduce the number of patients coming to the PHC Units.

An evaluation of COVID-19 Primary Care must consider technological support and remote approaches, which have been essential components of the health services delivered during the pandemic worldwide. For example, one Italian study suggested that everyone, worldwide, should have updated smartphone applications to facilitate communication between population and health professional teams^{3131 Bressya S, Zingarellib EM. Technological devices in COVID-19 primary care management: The Italian experience. Fam. Pract. 2020 [access on 2021 Feb 10]; 37(5):725-26. Available at: https://academic.oup.com/fampra/article/37/5/725/5841936?login=false.
https://academic.oup.com/fampra/article/...} . One Indian study indicated that this is the right time to increase our knowledge about the multifaceted digital health interventions available^{3232 Sarbadhikari S, Sarbadhikari SN. The global experience of digital health interventions in COVID-19 management. Indian J Public. 2020 [access on 2021 Feb 10]; 64(6):117-24. Available at: https://www.ijph.in/text.asp?2020/64/6/117/285593.
https://www.ijph.in/text.asp?2020/64/6/1...} . Chinese general practitioners suspended elective procedures and outpatient clinics and adopted online consultation and teleconsultation services^{3333 Tse DMS, Li Z, Lu Y, et al. Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China. Fam. Practice. 2020 [access on 2021 Dec 12]; 21(1):1-7. Disponível em https://link.springer.com/article/10.1186/s12875-020-01343-2.
https://link.springer.com/article/10.118...} . In a Greek study, it was found that the COVID-19 pandemic provided an opportunity to expand the telemedicine system to remote areas^{3434 Giannopoulou T, Giannopoulou I, Tsobanoglou G. COVID-19 pandemic: Challenges and opportunities for the Greek health care system. Irish J. Psyc. Med. 2020 [access on 2021 Feb 12]; 37(3):226-30. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7287301/.
https://www.ncbi.nlm.nih.gov/pmc/article...} , and studies conducted with Australian health professionals found that telehealth services were an integral part of the practices adopted during the pandemic^{2424 Kippen R, OSullivan B, Hickson H, et al. National survey of COVID-19 challenges, responses and effects in Australian general practice. Aust J Gen Pract. 2020 [access on 2021 Dec 12]; 49(11):745-51. Available at: https://search.informit.org/doi/abs/10.3316/INFORMIT.553734658477640.
https://search.informit.org/doi/abs/10.3...} . Spanish researchers have suggested that it is important to determine which factors are likely to influence the choice between telephone and video services, including the patient’s access to technology, the telemedicine infrastructure of the services, and the preferences of the patient and the doctor^{3535 Rodriguez JA, Betancourt JR, Sequist TD, et al. Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic. Am. J. Man. Care. 2021 [access on 2021 Dec 20]; 27(1):21-26. Available at: https://pubmed.ncbi.nlm.nih.gov/33471458/.
https://pubmed.ncbi.nlm.nih.gov/33471458...} .

In Brazil, the FHS, organized by territory and community oriented, is an appropriate model to support the population in the face of COVID-19 mitigation and containment measures^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} . There is evidence indicating that the PHC is the place where the majority of healthcare takes place and where trustworthy and long-term professional and patient relationships can be established^{66 Huston P, Huston JC, Grant R, et al. COVID-19 and primary care in six countries. BJGP Open. 2020 [access on 2022 Apr 27]; 4(4):bjgpopen20X101128. Available at: https://bjgpopen.org/content/4/4/bjgpopen20X101128?utm_source=trendmd&utm_medium=cpc&utm_campaign=BJGP_Open.
https://bjgpopen.org/content/4/4/bjgpope...} . However, to reduce morbidity and mortality, in addition to the potential of the FHS, it is necessary to have a PHC that is organized and structured with qualified professionals that are able to attend to local health needs^{11 Daumas RP, Silva GA, Tasca R, et al. The role of primary care in the Brazilian healthcare system: Limits and possibilities for fighting Covid-19. Cad. Saúde Pública. 2020 [access on 2021 Feb 27]; (36):e00104120. Available at: https://www.scielo.br/j/csp/a/LpxCJfYrMkRWnBr7K9pGnXv/?lang=en.
https://www.scielo.br/j/csp/a/LpxCJfYrMk...} . Permanent education and matrix support activities for professionals are also essential measures^{44 Medina MG, Giovanella L, Bousquat A, et al. Primary healthcare in times of COVID-19: What to do? Cad. Saúde Pública. 2020 [access on 2021 Feb 6]; 36(8):e00149720. Available at: https://www.scielosp.org/article/csp/2020.v36n8/e00149720/en/.
https://www.scielosp.org/article/csp/202...} , as well as promotion and prevention activities for the population on the correct hand hygiene and social distance. According to the results obtained, in more than 85% of PHC Units, health teams received training or guidance on the COVID-19 clinical management and prevention measures to advise the population.

In some countries, actions for tackling the COVID-19 pandemic had, to a large extent, major focus on hospital care. PHC involvement to respond the emerged situation varied according to the organization of health systems in different countries. There were examples, such as in China, India, and Cuba, where PHC assistance went through immediate reorganization. On the other hand, in some places, such as Spain, PHC professionals were allocated to hospitals, affecting PHC assistance. Facing a pandemic require individual and community approaches based on comprehensive and articulated care towards populational needs^{3636 Giovanella L, Martufi V, Mendoza DCR, et al. A contribuição da atenção primária à saúde na rede SUS de enfrentamento à Covid-19. Saúde debate. 2021 [access on 2022 Apr 28]; (44):161-76. Available at: https://www.scielo.br/j/sdeb/a/LTxtLz5prtrLwWLzNJZfQRy/abstract/?lang=pt.
https://www.scielo.br/j/sdeb/a/LTxtLz5pr...} . It is relevant to consider that a great part of the population in Brazil have PHC Units as their reference for health assistance, and this continued during the COVID-19 pandemic. Also, considering that appropriate and early approaches may prevent worsening of health conditions, it is crucial to determine strategies to empower and reinforce PHC response to the pandemic^{3737 Vitória AM, Campos GWS. Só com APS forte o sistema pode ser capaz de achatar a curva de crescimento da pandemia e garantir suficiência de leitos UTI. [São Paulo]: Cosems SP; 2020. [access on 2021 Oct 28]. Available at: http://www.cosemssp.org.br/wp-content/uploads/2020/04/So-APS-forte-para-ter-leitos-UTI-.pdf.
http://www.cosemssp.org.br/wp-content/up...} .

The permanent challenges in health management is undeniable, which should focus on the population needs to facilitate timely responses during crises. In this way, adapting working processes and services structures to enhance the PHC provision becomes favorable not only for tackling COVID-19, but also for future challenges.

Managers’ participation in the present study, assessing the structure and responsiveness of their PHC Units to COVID-19, has the potential for positive externalities. The participation may lead them to reflect on the strengths and weaknesses of PHC Units, as well as to drive them towards the best planning and management of activities, according to the needs of the current context and with the support of regional and central management of health services.

Conclusions

In addition to the challenges faced in responding to regular health services demands, the context of the COVID-19 pandemic brought the need for adaptation and new structural configurations in the provision of PHC services. The reorganization of the working process, health unit ambience, incorporation of equipment, laboratory supplies, and human resources, among other strategies, to mitigate the effects of the pandemic were in urgent need. This study demonstrated favorable adaptations and reorganization of working processes in PHC Units. In this context, it is relevant to highlight the power and capability of PHC workers to promote changes and adaptations in adverse scenarios. But the importance of the structural conditions provided to allow these initiatives must be emphasized. Interventions and tools designed to evaluate and monitor health services can contribute to planning and decision-making at different levels of management, which is crucial to determine strategies to empower and reinforce PHC response in situations of pandemics and other calamities.

References

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