Abstract

Primary Health Care (PHC) is an area of study that has improved remarkably in the last decades. In Brazil, this academic production is highly expressed in the field of Collective Health. This paper aims to analyze the PHC production published in the first 25 years of the “Journal Ciência & Saúde Coletiva” (C&SC). A narrative review was carried out, with analysis of the themes, methods, scale of analysis, partnerships, and authorship. A total of 295 papers were published, which corresponds to 5.9% of the total publications. A growing trend in papers addressing PHC was observed. The studies were mostly empirical (78.6%), with a qualitative approach (58.0%) and were predominantly local or municipal. Studies on health professionals were more frequent. The three prevailing themes were the health care model, PHC performance or effectiveness, and the work process. The profile found dialogues with the rich and diverse experience of Brazilian PHC. However, the incorporation of broader analyses is still challenging. The published papers highlighted the debates and contributed to the reflection and dissemination of the experience of Brazilian PHC, which was and is central to the construction of the Brazilian Health System.

Key words:
Primary Health Care; Bibliometrics; Periodicals as topic

Introduction

The first 25 years of the Journal Ciência & Saúde Coletiva (C&SC), edited by the Brazilian Association of Collective Health (Abrasco), are contemporary to the process of building the Brazilian Unified Health System (SUS). The C&SC pages reflected many of the debates, disputes, questions, achievements, and setbacks of this period¹1 Minayo MCS, Gomes R. Cien Saude Colet no contexto nacional e internacional da divulgação científica. Cien Saude Colet 2015; 20(7):2013-2022..

Undoubtedly, the establishment and implementation of the SUS produced essential changes in the distribution of political power and responsibilities among the spheres of government (national, state and municipal), between the State and civil society through new mechanisms of social participation and necessary decentralization process, with the transfer of decision-making power and competences from national to subnational levels. Another central point in the SUS construction was the definition of the care model and the role of Primary Health Care (PHC) in this model²2 Paim J. Atenção primária à saúde: uma receita para todas as estações? Saúde em Debate 2012; 36(94):343-347.^,33 Paim JS. Modelos de Atenção à Saúde no Brasil. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 459-492..

The SUS design was influenced by several proposals for health care models with different rationales and previous local experiences, which have shaped new approaches in PHC and care models always in a dispute over the first three decades, driven by national policies, including relevant political, managerial and organizational changes³3 Paim JS. Modelos de Atenção à Saúde no Brasil. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 459-492.^,44 Giovanella L, Mendonça MHM. Atenção Primária à Saúde. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-346.. Disputes over the SUS care model permeated the critical expansion of primary care services and the Family Health Strategy (ESF) over more than 20 years, founded on different conceptions of the right to health and the organization of professional practices and inclusions: between universal access and focused care, between emergency and comprehensive care, response to group and individual needs, self-referred and scheduled demand, among others⁴4 Giovanella L, Mendonça MHM. Atenção Primária à Saúde. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-346..

What Viana and Dal Poz (2005) have labeled as “program void” since the creation of the SUS⁵5 Viana AL, Dal Poz MR. A Reforma do Sistema de Saúde no Brasil e o Programa de Saúde da Família. Physis 2005; 15(Supl.):225-264. begins to fill in, in the 1990s, a model to reorient care practice, consistent with the principles of universality, comprehensiveness, and equity with the Family Health Program (PSF). While initially conceived as focused programs, PACS (1991) and PSF (1994) targeted population groups without access and with a selective scope of actions, promoted innovative reorientation of the care model in the SUS, combining the individual care practice with the population approach from the perspective of territorialized health surveillance²2 Paim J. Atenção primária à saúde: uma receita para todas as estações? Saúde em Debate 2012; 36(94):343-347.^,44 Giovanella L, Mendonça MHM. Atenção Primária à Saúde. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-346.^,66 Teixeira CF. A mudança do modelo de atenção à saúde no SUS: desatando nós, criando laços. In: Teixeira CF, Solla JP, organizadores. Modelo de atenção à saúde: promoção, vigilância e saúde da família. Salvador: Edufba; 2006. p. 19-58.. Over time, elements found in several models, such as program actions to priority groups, reorganization of the self-referred demand with user-centered reception, and multidisciplinary support, were incorporated into the PSF now called the Family Health Strategy (ESF)⁷7 Schraiber LB, organizador. Programação em Saúde Hoje. São Paulo: Hucitec; 1993.^,88 Cunha GT, Campos GWS. Apoio Matricial e Atenção Primária em Saúde. Saude Soc 2011; 20(4):961-970..

From the 2000s, PHC’s attributes synthesized by Starfield⁹9 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde (MS); 2002. (first contact, scope/comprehensiveness, longitudinality/relationship and coordination, family orientation, community orientation, and cultural competence) started to be disseminated in publications nationwide. They were incorporated into the National Primary Health Care Policy (PNAB) 2006⁴4 Giovanella L, Mendonça MHM. Atenção Primária à Saúde. In: Giovanella L, Escorel Sarah, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-346.. Moreover, efforts to evaluate PHC services began to be induced by the Ministry of Health (MS) through PHC assessment institutionalization initiatives in the SUS¹⁰10 Almeida PF, Giovanella L. Avaliação em Atenção Básica à Saúde no Brasil: mapeamento e análise das pesquisas realizadas e/ou financiadas pelo Ministério da Saúde entre os anos de 2000 e 2006. Cad Saude Publica 2008; 24(8):1727-1742..

In 2011, PNAB underwent the first review, which revised the concept of PHC and incorporated actions developed by new devices, such as the Family Health Support Center (NASF), created in 2008, from the perspective of interprofessionality, multidisciplinary support, continuing education, shared clinical responsibility for a higher care resolution, and the financing of different modalities of EFS teams. In the same decade, policies for improving the physical infrastructure of the PHC units (UBS) (Requalifica), access and quality (PMAQ-AB), and providing doctors (PMM) stood out, all historical problems for the sustainability and expansion of PHC.

It is worth mentioning that, as of 2017, increasingly intense political conflicts, which are expressed both in attacks on democracy and in setbacks for the advances obtained by the implementation and expansion of a community-based PHC care model, materialized in the latest review of the PNAB and several subsequent PHC-related policies¹¹11 Melo EA, Mendonca MHM, Oliveira JP, Andrade GCL. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde debate 2018; 42(n esp. 1):38-51.^,1212 Giovanella L, Bousquat A, Almeida PF, Melo EA, Medina MG, Aquino R, Mendonça MHM. Médicos pelo Brasil: caminho para a privatização da atenção primária à saúde no Sistema Único de Saúde? Cad Saude Publica 2019; 35(10):e00178619..

These advances and setbacks are expected to have repercussions on the content of publications in the C&SC. After all, one of the outstanding characteristics of Public Health is to be a field that articulates knowledge and practice. Moreover, unlike other countries, one of Brazilian PHC’s features is its proximal interface with Public Health, its critical territorialized approach and the presence of multiprofessional teams. In this scenario, this paper aims to analyze the path of the PHC knowledge production disseminated in the first 25 years in the Journal C&SC. It is assumed that this production is related to changes in national and local health policies and processes to promote research and institutionalize evaluation initiatives over the period.

Material and methods

A narrative review of the PHC production published in the Journal C&SC from 1996 to 2019 was carried out. The search for papers was performed on the SciELO platform, which makes available all papers published in the period. Initially, we included works that contained the following keywords in any of the search indexes: “Primary Care”, “Basic Care”, “Family Health”, “Community Health Worker”, “Family Health Strategy”, and “Family Health Program”. Then, the selection was expanded with the inclusion of papers with the following keywords: “Reception”, “Home Care”, “Primary Health Care”, “More Doctors Program”, and “Basic Health Services”. The last step was accessing all thematic issues addressing PHC, identifying possible losses from previous strategies. These numbers were identified on C&SC’s website, which provides all published issues.

The initial search identified 367 papers. Each abstract was read separately by two researchers who had been studying PHC for at least 20 years. Papers that addressed a topic relevant to the PHC scope were selected, and any disagreement was resolved by a third researcher who made a new assessment. In this process, 72 works were excluded, and the 295 papers included were analyzed and classified.

The theme and sub-theme addressed, the methods used, the type of paper, the scale of analysis, the institutional partnerships established, the language of publication, and the authorship profile were analyzed for each of the selected works. An Excel database was prepared with the primary bibliographic data for all included papers. This spreadsheet was exported and analyzed using the IBM SPSS Statistics version 23 program. The main themes addressed in the papers were grouped into the following categories: policy analysis; financing, costs and application of resources; care model; articulation of PHC in health care networks; health management; work process; work management; training and continuing education; access, accessibility, coverage, and use of services; PHC performance or effectiveness; user profile; perception of illness and care processes; health promotion; family; health education; reform of other health systems. The definitions adopted are presented in Chart 1.

The “subthemes” of the papers were also identified, considering specific approaches to the theme as subthemes, notably regarding problems, program area, and professional or political category. For example, a study on user accessibility in the context of the More Doctors Program (PMM) was classified in the theme “access, accessibility, coverage and use of services” and in the subtheme as “More Doctors Program”; a paper that addressed the oral health professionals’ work process was classified under “work process”, with subtopic “oral health”. All papers were classified by theme, but only those that highlighted any specific focus in their abstracts were classified under the subtheme.

Regarding methodological aspects, the first categorization was related to the type of approach - quantitative or qualitative. Then, the 295 papers were classified as empirical, using primary or secondary data; or theoretical-conceptual, which corresponded to a set of productions - essays, debates, opinions and reviews - characterized by the expression of value judgments or viewpoints on PHC, although in some cases, empirical evidence was used. In a third step, the scope of the study was identified only for the empirical papers (n = 232) - local, municipal/district, regional, state, large regions/national, international - and the subjects involved in data production - users, professionals, administrators/managers, health councils/social participation, others and does not apply (papers based on secondary data and documents).

The institution and country of the first author, the total number of authors and the number of institutions involved were considered, and whether institutions located in more than one state of the federation or country were included in order to characterize authorship and institutional partnerships. Disseminating languages have also been listed.

The number of papers listed was compared to the total number of papers published in the Journal C&SC, which were manually retrieved from the journal’s page on SciELO, considering all works published in all the journal’s sections.

Results

The 295 papers that looked at PHC in the Journal C&SC were analyzed, which corresponded to 5.9% of the journal’s total publications between 1996 and 2019. The absolute number varied over the years, but an increasing trend line of PHC production at C&SC was observed (Figure 1) despite the variation, which partly results from the publication of eight PHC-related thematic issues in these first 25 years of C&SC, with 107 papers published in the thematic issues. It is worth mentioning that the first work on the topic was published only in 2002.

The special issues concentrated 36.3% (n = 107) of all production on PHC. The topics covered were evaluation as a change strategy; multi-professionality in the then Family Health Program; Primary Care in the care of diseases and conditions; Family Health expansion and challenges; PHC and family health; PHC reform in the city of Rio de Janeiro; the More Doctors Program; and, finally, a comparative analysis of PHC in the cities of Lisbon and Rio de Janeiro.

The mean number of authors per paper was 3.9, with a median of 3 and a standard deviation of 2.1. As for the language, only 10 works (3.4%) were published exclusively in a language other than Portuguese. A growing bilingual number of publications was observed, especially in the last five years, with 29.8% of publications also being published in English and only six papers in Spanish.

Considering the institutions of first authors, the journal published mainly Brazilian authors (93.6%), followed by Portuguese (3.7%), and most of them were women (63.7%). Among Brazilians, the authors originated predominantly from institutions in Rio de Janeiro (18.0%), São Paulo (17.6%), Federal District (9.5%), Minas Gerais (9.2%), Rio Grande do Sul (8.5%). No first authors from institutions in Acre, Roraima, Rondônia, Amapá, Sergipe were identified, and only two works were related to the state of Amazonas and one to the state of Pará.

Although most studies have been carried out by researchers from more than one institution (59.0%), in only 24.1% of these, this collaboration covered different states of the federation (Table 1).

Most studies used a qualitative approach (58.0%). Empirical studies were predominant (78.6%), although a vital percentage was characterized as theoretical-conceptual papers that included essays, debates, reviews, and opinion papers. The scope of most of the empirical papers (68.1%) was local and municipal/district-related. Few were national (11.2%), in general, resulting from evaluation processes induced by the Ministry of Health, such as PROESF and Self-assessment for the Improvement of Access and Quality of Primary Care (AMAQ), besides studies using the approach of Primary Care-Sensitive Hospitalizations (PSCH) and Primary Care Assessment Tool (PCATool) (Table 1).

As for the population studied, works on health professionals were more frequent, followed by users and managers. Approaches with more than one category were rarer (Table 1). Only three papers focused on health councils. Moreover, almost a quarter of the empirical studies used secondary data or documents as data sources, grouped as Unspecified (Table 1).

Concerning the thematic classification, three themes predominated, accounting together for more than 50% of the studies: care model (18.3%), PHC performance or effectiveness (17.0%), and work process (15.3%) (Table 2). If we add to the previous three the themes of “Access, accessibility, coverage, and use of services” (4.8%) and “Articulation of PHC in healthcare networks” (3.4%), we can see that the focus of researchers in almost 60% of the papers on PHC published in the journal were aspects related to the directionality and effectiveness of PHC change regarding the SUS construction process and the Brazilian Health Reform. The remaining 40% of the papers addressed several topics, and, in isolation, none reached a percentage equal to or greater than 10%: “Health management” (9.2%), “Training and Continuing Education” (7.5%), “Analysis of the Brazilian PHC policy” (5.8%), “Reform of other health systems” (4.1%), “Articulation of PHC in health care networks” (3.4%), “Perception of illness and care” (3.7%), and others, which did not reach 3% of the analyzed works (Table 2). Regarding the reform of other health systems globally, papers that analyzed PHC in Portugal, Germany, Chile, Paraguay, Uruguay, Argentina, and Spain and Latin America as a whole were published.

Comparing the empirical or review papers with the group of papers that aggregated the essays, debates, and opinion papers, “Care model” and “Work process” remained as favored themes in both groups. Most works that addressed “PHC performance or effectiveness” were from the group of empirical or review papers, while “Policy analysis” in general was addressed in essays, debates, or opinion papers.

A specific sub-theme was identified for 227 papers, grouped in Table 3 according to certain similarities concerning focus. We observed that about 30% of the works focused on some PHC program area, emphasizing Oral Health (7.9% of the total and more than 25% of the papers in this subgroup).

Another expressive subgroup in this analysis, with 16.7%, addressed aspects related to the team’s professionals, such as, for example, practices or continuing education processes. In half of the cases, the professional in question was the ACS. We could identify aspects related to the health care model as subthemes, such as health surveillance and social participation, multidisciplinary support, and PHC attributes, in about 10% of the papers. A significant number of works, corresponding to almost 10%, focused on health diseases and problems, especially chronic diseases (3.5% of the total papers). Finally, it is worth noting the high percentage that addressed the More Doctors Program (7.9%), which was the subject of a particular supplement. The other subthemes were widely dispersed, with percentages around or below 5%, indicating the full range of investigated aspects of PHC.

Discussion and considerations

This paper aimed to identify the scientific production on PHC published in the C&SC. Thus, while it dialogued with the Brazilian Collective Health field production on the subject, the results presented here are limited to works published in the C&SC. The volume found is in line with the results obtained by Medina et al.¹³13 Medina MG, Aquino R, Vilasbôas ALQ, Nunes CA. A Pesquisa em Atenção Primária à Saúde no Brasil. In: Mendonça MHM, Matta G, Gondin R, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: Conceitos, Práticas e Pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. p: 453-492., who identified an essential production on Brazilian PHC, reaching more than 860 papers from 1980 to 2016. While the selection criteria adopted were different from those used here, the authors identified that C&SC was the journal with the second highest circulation of production, behind Cadernos de Saúde Pública, in a total of 153 journals. In this scenario of high dispersion in the dissemination of knowledge about PHC, the number of works found here corroborates that C&SC was and is a journal central to the construction of knowledge about Brazilian PHC within the SUS.

The first paper on PHC in C&SC was published only in 2002, seven years after the onset of the journal, and about a decade after the onset of the PACS/PSF experience, coinciding with a higher ESF coverage in Brazil. The gap between practice and the dissemination of scientific production, especially empirically-based production, is not exclusive to C&SC, nor Brazilian production¹³13 Medina MG, Aquino R, Vilasbôas ALQ, Nunes CA. A Pesquisa em Atenção Primária à Saúde no Brasil. In: Mendonça MHM, Matta G, Gondin R, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: Conceitos, Práticas e Pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. p: 453-492.^,1414 Hummers-Pradiers E, Scheidt-Nave C, Martin H, Heinemann S, Kochen MM, Himmel W. Simply no time? Barriers to GP's participation in primary health care research. Family Practice 2008; 25(2):105-112.. Hirschhorn et al.¹⁵15 Hirschhorn LR, Langlois EV, Bitton A, Ghaffar A. What kind of evidence do we need to strengthen primary healthcare in the 21st century? BMJ Global Health 2019; 4(Supl. 8):e001668 reinforce the urgent need to produce, with agility, research and new evidence to strengthen PHC in health systems. An increased production of works has been noted since the publication of the first paper, following the political priority given to Family Health, with all the challenges in this process¹⁶16 Sousa MF, Hamann EM. Programa Saúde da Família no Brasil: uma agenda incompleta? Cien Saude Colet 2009; 14(Supl. 1):1325-1335..

The number of papers published annually varied, which may reflect both investments in the evaluation processes implemented by the Ministry of Health and the publication of thematic issues. Despite this variation, we can affirm unequivocally that PHC is a relevant topic with increasing space in C&SC.

If, in general, increased production on PHC is noted in C&SC, this dissemination still reflects, on the one hand, a large concentration of first authors from the wealthiest states of the federation. On the other hand, the absence of authors from several states, and the almost inexistence of first authors from the north region is a significant aspect of the unequal production of knowledge. This picture also reflects somewhat the distribution of public health masters and doctoral courses.

The production on PHC at C&SC refers mainly to local experiences, through a qualitative approach, published in Portuguese. An “inward dialogue” is observed, perhaps influenced, among other aspects, by the decentralized Brazilian health system model, whose financial onlendings from the central level to the municipalities, and the attribution of implementation responsibilities to the local entity, produced a mosaic of PHC experiences, portrayed by academic production in the area. While this is a characteristic of the rich and diverse Brazilian PHC, the challenge remains to make scientific production further recognized and debated internationally. Indeed, the dissemination in more than one language will contribute to this end.

Another aspect that cannot be overlooked when analyzing PHC production is the strong influence of federal policies for institutionalizing PHC monitoring and evaluation by federal management. A turning point was the creation of the Primary Care Monitoring and Evaluation Coordination Office at DAB/SAS/MS¹⁷17 Felisberto E. Da teoria à formulação de uma Política Nacional de Avaliação em Saúde: reabrindo o debate. Cien Saude Colet 2006; 11(3):553-563. in 2003. Initiatives were also developed by the Department of Science and Technology (DECIT) of the Department of Science, Technology and Strategic Supplies/MS and joint public notices with the National Council for Scientific and Technological Development (CNPq), besides support for state research promotion agencies in the Research for SUS Program, which may justify the increased dissemination of production on the theme in the C&SC.

The Ministry of Health’s strategy of including universities as partners in the evaluation processes undoubtedly contributed to the growth of scientific production on the subject. This strategy was initially financed to research evaluation with sparse requests from academic institutions. It evolved in 2005 to the Expansion and Consolidation Project of the Family Health Strategy (PROESF) which promoted a set of baseline evaluative studies, encompassing 227 municipalities with a population over 100,000 inhabitants, which boosted evaluative research in primary care, especially with the use of cross-sectional design, combination of methods and case study by intentional sampling, and approach to managers, professionals, and users. These studies were present in the C&SC¹⁸18 Bodstein R, Feliciano K, Hortale VA, Leal MC. Estudos de Linha de Base do Projeto de Expansão e Consolidação do Saúde da Família (ELB/Proesf): considerações sobre seu acompanhamento. Cien Saude Colet 2006, 11(3):725-731.

19 Elias PE, Ferreira CW, Alves MCG, Cohn A, Kishima V, Escrivão Junior A, Gomes A, Bousquat A. Atenção Básica em Saúde: comparação entre PSF e UBS por estrato de exclusão social no município de São Paulo. Cien Saude Colet 2006; 11(3):633-641.^-2020 Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Rodrigues MA. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da Atenção Básica à Saúde. Cien Saude Colet 2006, 11(3):669-681..

On the other hand, another significant evaluative movement in the PHC scenario, namely, the Program for the Improvement of Access and Quality of Primary Care (PMAQ-AB), has not been reflected significantly in the production of PHC the Journal C&SC.

The studies from the PMAQ-AB published in the various journals were, in general, supported by cross-sectional designs with PHC professionals and users, combining mixed-methods (qualitative-quantitative) approaches, and different research techniques that allowed valuing the perception of its implementers and beneficiary citizens regarding the problems of care concerning structure, processes, and satisfaction of health needs²¹21 Mendonça MHM, Giovanella L, Fausto MCR, Lima JG, Escorel S, Almeida PF, Pilar AA. Melhoria da Qualidade nas práticas de Atenção Primária à Saúde. In: Sá MC, Tavares MFL, De seta MH, organizadores. Organização do Cuidado e Práticas em Saúde - abordagens, pesquisa e experiências de ensino. Rio de Janeiro: Editora Fiocruz; 2018. p. 257-293.. In the C&SC, the papers relying on the PMAQ-AB databases of the first two evaluation cycles worked on new hypotheses when associated with other programs, such as the PMM or the effectiveness of family health training for comprehensive care in the ESF²²22 Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das Unidades Básicas de Saúde. Cien Saude Colet 2016; 21(9):2697-2608.^,2323 Santos NML, Hugo FN. Formação em Saúde da Família e sua associação com processos de trabalho das Equipes de Saúde Bucal da Atenção Básica. Cien Saude Colet 2018; 23(12):4319-4329..

In 2013, the More Doctors Program (PMM) produced an inflection in the national primary care policy, bringing to light the immense hardships in providing services in remote and more vulnerable areas²⁴24 Organização Pan-Americana da Saúde (OPAS). Programa Mais Médicos no Brasil. Panorama da Produção Científica. Brasília: OPAS; 2017, In a short span, such policy generated an expressive set of publications, and the special issue of C&SC on the PMM produced in 2016 was considered the primary vehicle for the dissemination of opinion papers and debate on the PMM, and empirical papers with research results²⁵25 Facchini LA, Batista SR, Silva Júnior AG, Giovanella L. O Programa Mais Médicos: análises e perspectivas. Cien Saude Colet 2016; 21(9):2652..

The set of C&SC production is still focused on the national dimension, with several empirical studies analyzing the implementation of structural policies geared to strengthening PHC such as PROESF, PMAQ and, PMM, and or theoretical, review, or essay studies that capture the trend of the PHC structuring process in the country. However, analysis on a national scale, based on the data produced by these processes, is negligible, especially when taking as a parameter the full availability of the dataset related to the Brazilian PHC situation²⁶26 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(n. esp. 1):208-223.. The low dissemination of these studies contrasts with the Brazilian PHC structuring process, which has consolidated a national care model in recent decades, with the establishment of practices, regulations, innovations, and reflections arising from the different national management practices, with intense dialogue between the governmental levels, which sets up the rich Brazilian experience in PHC in renewing the management and care models due to the health decentralization process.

The significant presence of empirical works with municipal or local scope, close to 70% of the studies, was also found in other reviews¹³13 Medina MG, Aquino R, Vilasbôas ALQ, Nunes CA. A Pesquisa em Atenção Primária à Saúde no Brasil. In: Mendonça MHM, Matta G, Gondin R, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: Conceitos, Práticas e Pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. p: 453-492.^,2727 Giovanella L, Mendonça MHM, Medina MG, Lima JG, Fausto MCR, Seidl HM, Andrade GCL, Facchini LA. Contribuições dos Estudos PMAQ-AB para a avaliação da APS no Brasil. In: Mendonça MHM, Matta G, Gondim R, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: Conceitos, Práticas e Pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. p. 569-610.

28 Ribeiro LA, Scatena JH. Avaliação da atenção primária à saúde no contexto brasileiro: uma análise da produção científica entre 2007 e 2017. Saúde Soc 2019; 28(2):95-110.^-2929 Arantes LJ, Shimizu HE, Merchán-Hamann E. Contribuições e desafios da Estratégia Saúde da Família na Atenção Primária à Saúde no Brasil: revisão da literatura. Cien Saude Colet 2016; 21(5):1499-1510.. On the one hand, this result is associated with municipalities spearheading innovative experiences, which are frequently set as study objects, but also shows a mismatch between scientific production in PHC and the broad national PHC program - mostly qualitative studies, focused on few research groups, with elaboration hardly shared with other groups.

As for the themes, the predominance of analyses on the “PHC care model, performance or effectiveness” and “work process” reveals the researchers’ concern in analyzing the expected changes regarding the process of implementing the Brazilian PHC model, by means of the reorientation of care practices and their organizational rationale, and its results concerning population health indicators. In the first case, the results aim to contribute to the knowledge of aspects related to the technological arrangements of PHC care organization, including devices such as multidisciplinary support to teams and highlighting the investigation of the main PHC attributes, such as comprehensiveness, longitudinality and family and community orientation.

The debate around the health care model is central to the process of building the SUS, which is the cause of a movement in favor of international health systems reforms and expresses disputes between the so called biomedical model versus alternative models, shifting the object centrality and the service organization from the disease-hospital binomial to the individual-family-community-territory of health promotion and care production³⁰30 Teixeira CF, Vilasbôas ALQ. Modelos de atenção à saúde no SUS: transformação, mudança ou conservação? In: Paim JS, Almeida-Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro; Medbook: 2014. p 287-301.^,3131 Teixeira CF. PAIM JS, Vilasbôas ALQ. SUS, modelos assistenciais e vigilância da saúde. Informe Epidemiológico do SUS 1998; 7(2):7-28.. While highlighted as a specific theme, the PHC policy shows a given cross-sectionality and interface with other themes presented in the papers such as “work process”, “articulation of PHC in health care networks”, and is addressed in several studies that focus on overall policy analysis.

The analysis of PHC’s effectiveness in the organization of services and the health of the population has been gaining space in national and international literature²⁶26 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(n. esp. 1):208-223.^,3232 Macinko J, Starfield B, Erinosho T. The impact of primary healthcare on population health in low- and middle-income countries. J Ambul Care Manage 2009; 32(2):150-171.^,3333 Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Contribuição para uma agenda política estratégica para a Atenção Primária à Saúde no SUS. Saúde em Debate 2018; 42(n. esp. 1):406-430. since PHC is a favorable scenario to induce significant changes in individual and community illness standards. This is because PHC can promote the incorporation of new health promotion and disease prevention practices, expand accessibility to PHC actions and services, and other levels of complexity of the health system, by imprinting new organizational dynamics in health units. Concerning the third most discussed topic, namely, the work process, the authors further discussed professionals’ practices and their attributions and reflected upon the role of several health categories, especially the community health worker. The ACS highlight reveals its relevance in constructing the Brazilian PHC model, as underscored by several authors³⁴34 Costa SM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Cien Saude Colet 2013; 18(7):2147-2156.

35 Gomes KO, Cotta RMM, Mitre SM, Batista RS, Cherchiglia ML. O Agente^-3636 Comunitário de Saúde e a consolidação do Sistema Único de Saúde: reflexões contemporâneas. Physis 2010; 20(4):1143-1164..

The papers that addressed health management, highlighting the profile, competencies, and practices of managers, including the use of technologies, and those that discussed the various training and continuing education initiatives of health professionals, show their concern with the necessary qualification of PHC to fulfill its essential functions. Noteworthy is the low presence of other relevant themes, such as the articulation of PHC in the care network, work management, financing, health promotion, health education and reflections on the family - critical knowledge gaps deserving further analysis, and which represent obstacles to be overcome by the Brazilian PHC.

Undoubtedly, the pages published in the first 25 years of C&SC highlighted the debates and contributed to the reflection and dissemination of the rich experience of Brazilian PHC. A special issue on Alma Ata’s 40 years was published in 2020, keeping with this important tradition, and we invite readers to visit it³⁷37 Pereira IC, Oliveira MAC. O trabalho do agente comunitário na promoção da saúde: revisão integrativa da literatura. Rev Bras Enferm 2013; 66(3):412-419.. The set of production on PHC in these 25 years provides central reflections for the consolidation of the project of an equitable and comprehensive Brazilian health system: our SUS. Indeed, future C&SC pages will continue to disseminate these experiences and debates.

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