Abstract

The municipality of São Paulo has historically been marked by a heterogeneous implementation and coexistence of conflicting models of SUS management and Primary Health Care (PHC). The administration of health services management contracts was consolidated and associated with a productivist rationale. The selective PHC weaknesses tend to be pronounced during the COVID-19 pandemic. Thus, the present article aims to analyze work management and care in PHC during the COVID-19 pandemic in the municipality of São Paulo through a multicenter qualitative research anchored in the Paideia theoretical framework. We conducted 31 in-depth interviews with PHC clients and workers, along with participant observation. We noted the municipal management’s authoritarian and managerialist stance when conducting the responses, with little room for listening and dialogue. We identified weakened collective spaces and service-community bond, bureaucratization and precariousness of work processes, and NASF’s dismantling. In this setting, care was characterized by significantly reducing the expanded and shared clinical practice and the distancing from the territorial and community-based PHC guidelines.

Key words:
Primary Health Care; Health Management; Unified Health System

Introduction

Primary Health Care (PHC) plays a fundamental role in the organization of the health care network in the Unified Health System (SUS). The Family Health Strategy (ESF) model ensures consolidated and expanded coverage, including individual, family, and community actions toward promoting and protecting health, prevention, diagnosis and treatment of diseases and illnesses, rehabilitation actions, harm reduction, palliative care, and health surveillance. It is territorially and community-based and oriented to act from an interdisciplinary, interprofessional, and intersectoral perspective¹1 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017..

PHC played a fundamental role in some municipalities during the COVID-19 pandemic, emphasizing the multidisciplinary action of the ESF teams, with Community Health Workers (ACS) developing surveillance, active search, follow-up, and monitoring people’s health²2 Giovanella L, Franco CM, Almeida, PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482..

Brazilian PHC was being de-characterized even before the pandemic, with the gradual dismantling of the ESF model, which strengthens the territorial and community approach, prioritizing the so-called traditional Primary Care, as observed in the unfolding of the latest edition of the National Primary Healthcare Policy³3 Melo EA, Mendonça MHMD, Oliveira JRD, Andrade GCLD. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saude Debate 2018; 42:38-51.. At the federal level, the austerity agenda radicalized from 2016 - with Constitutional Amendment No. 95, which froze public spending⁴4 Brasil. Ministério da Saúde (MS). Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União; 2016.. The neoliberal and mercantile logic was advanced over the management of PHC in the SUS with the implementation of the Previne Brasil Program, changing rules for funding PHC and setting and regulating the Primary Healthcare Development Agency (ADAPS)⁵5 Brasil. Ministério da Saúde (MS). Portaria nº 3.222, de 10 de dezembro de 2019. Dispõe sobre os indicadores do pagamento por desempenho, no âmbito do Programa Previne Brasil. Diário Oficial da União 2019; 11 dez.^,66 Brasil. Lei nº 13.958, de 18 de dezembro de 2019. Institui o Programa Médicos pelo Brasil, no âmbito da atenção primária à saúde no Sistema Único de Saúde (SUS), e autoriza o Poder Executivo federal a instituir serviço social autônomo denominado Agência para o Desenvolvimento da Atenção Primária à Saúde (Adaps). Diário Oficial da União 2019; 19 dez..

The implementation of the SUS and the history of PHC construction are characterized by constant ruptures in São Paulo. While it was a pioneer between 1989 and 1992 in implementing the SUS, in 1996, under the administration of Paulo Maluf, the municipal management withdrew from SUS implementation and adopted the Health Care Plan (PAS) as a management model. The PAS follows the World Bank ideas that bring precedence of economic reason to social policies, in which production and services are delivered to medical cooperatives with public financing. In parallel, part of the UBS was owned by the state government and organized under Health Centers. In 1996, while the municipality had adopted the PAS model, which retrocedes its entry into total SUS management, the state government implemented the first Family Health Program (PSF) units in the far east of the city, Itaquera⁷7 Pinto NRS, Tanaka OY, Spedo SM. Política de saúde e gestão no processo de (re)construção do SUS em município de grande porte: um estudo de caso de São Paulo, Brasil. Cad Saude Publica 2009; 25(4):927-938..

In 2001, under new management, São Paulo returned to total management of the SUS and began the UBS municipalization process with an expanded PSF to prioritize it as a municipal model. Then, partnerships with Social Health Organizations (OSS) were scaled up through agreements to recruit human resources. In 2005, a new service called Ambulatory Medical Care (AMA) was implemented, coupled with the UBS, hiring on-duty doctors. The UBS stopped responding to the walk-in demand, leaving it to the AMA based on a “treat-and-street” care model, disconnected from longitudinal monitoring, overly affecting PHC⁷7 Pinto NRS, Tanaka OY, Spedo SM. Política de saúde e gestão no processo de (re)construção do SUS em município de grande porte: um estudo de caso de São Paulo, Brasil. Cad Saude Publica 2009; 25(4):927-938..

Furthermore, the managerialist and productivist logic is forcefully established in management contracts between the municipal secretariat and the OSS. Goals and performance indicators are now established arbitrarily, without the participation of workers and patients, and disconnected from local health needs. Thus, Hegemonic Managerial Rationality predominates, which escalates worker alienation and undermines care, with social stakeholders who no longer recognize the use value or purpose of their work process⁸8 Mendes Á, Melo MA, Carnut L. Análise crítica sobre a implantação do novo modelo de alocação dos recursos federais para atenção primária à saúde: operacionalismo e improvisos. Cad Saude Publica 2022; 38(2):e00164621..

Considering the importance of PHC’s performance during the COVID-19 pandemic and the complex history of health management in São Paulo, this article aims to understand work management in PHC in the capital of São Paulo state during the pandemic and analyze care offered from the perspective of clients and workers.

Methods

This qualitative research produced data through participant observation, with field diary recording and in-depth interviews. The research was anchored in the Paideia⁹9 Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013. framework, which operates with the triple purpose of expanding understanding of a topic, conducting an institutional analysis and an analysis of power relationships, enabling people to think of themselves as unique agents of this social network.

The present article is nested in the multicenter study “Strategies for approaching subjective and social aspects in PHC in the pandemic”, which involved data collection in the municipalities of São Paulo, Rio de Janeiro, and Campinas. The results presented here refer to the city of São Paulo.

We adopted convenience sampling. The research coordination previously contacted one of the Regional Health Coordination Offices in São Paulo to facilitate access to the field. The UBS were selected with the management of the Municipal Health Secretariat (SMS) and the respective OSS, under the following criteria: covering four distinct territories, having an ESF team, and being located in a socially vulnerable territory. The characterization of the UBS is found in Chart 1, and fictitious names were given to preserve anonymity: Ametista, Esmeralda, Ruby, and Turmalina.

Considering the active role of the researcher in this type of qualitative study, which values interaction with the subjects, an immersion and recognition of the functioning of the UBS was conducted initially, recording in a field diary, providing complementary data for the analysis¹⁰10 Minayo MCS. O desafio do conhecimento: Pesquisa qualitativa em Saúde. 4ª ed. São Paulo: Hucitec; 2010.. Four field researchers were responsible for connecting to one of the UBS for immersion and conducting interviews. This process began in August 2021, and the interviews were completed in March 2022. We should underscore that the researchers entered the units during the onset of vaccination against COVID-19.

Once the researchers were immersed in the study context, key informants that could indicate participants for the interviews were identified among the health teams and clients. Informants had to consider the following inclusion criteria: 1) for clients: men and women, aged eighteen or over, residing in the territory assigned by the UBS; preferably, women family leaders or activists, dwellers in situations of social vulnerability related to work, income, and low-income family and social ties; violence victims; with difficulty accessing social protection policy equipment; Black population; people with disabilities; LGBTQIA+ people or individuals with some psychological illness. 2) for workers: professionals from UBS with the ESF model, from the Expanded Family Health Center (NASF), and Street Office, with at least one year of working experience in the territory and linked to the care of the indicated clients.

In this way, 15 workers and 16 clients participated in the interviews. We adopted theoretical saturation as a criterion for finalizing data collection after redundancy and repetition of the contents of interest.

The interviews started with a triggering question: workers were asked, “What do you, SUS and APS worker, believe has changed in your work after the pandemic?” and for clients, “What happened to you and your family after the pandemic?”. A thematic map that addressed subjective and social aspects guided field researchers to sensitize them to listening and deepening the experiences brought by the respondents.

The number of meetings necessary to go through the proposed roadmap varied between one and three in each interview, as some cases required resuming dialogue to analyze further or clarify a point. All interviews were recorded and transcribed after the participants’ consent.

Based on their immersion in the units, the field researchers invited workers directly to be interviewed after presenting the project and agreeing with local management on conducting the interviews at the UBS premises during working hours. Regarding clients selected from the criteria mentioned above, with the support of health teams, the invitation was made during home visits to present the research and offer the possibility of participation. Several community spaces were used, from public spaces to the environment of their homes. See Chart 2 for a more detailed understanding of the characteristics of the interviewed population.

For the analysis, we constructed narratives and proceeded with validation by peers, field researchers, and project coordinators¹¹11 Onocko-Campos R, Furtado JP. Narrativas: apontando alguns caminhos para sua utilização na pesquisa qualitativa em saúde. In: Onocko-Campos R, Furtado JP, Passos E, Benevides R, organizadores. Pesquisa avaliativa em saúde mental: desenho participativo e efeitos da narratividade. São Paulo: Hucitec; 2008. p. 321-334.^,1212 Onocko-Campos R. Inovações para o estudo e a produção de consensos: além do Delphi. In: Onocko-Campos R, Furtado JP. Desafios de avaliação de programas e serviços em saúde. Campinas, São Paulo: Editora da Unicamp; 2011.. Field researchers were responsible for building a narrative (regardless of the number of meetings held) for each subject they interviewed. Another research group member listened to the interview’s audio recordings, read the narrative, and suggested changes to its form or content¹¹11 Onocko-Campos R, Furtado JP. Narrativas: apontando alguns caminhos para sua utilização na pesquisa qualitativa em saúde. In: Onocko-Campos R, Furtado JP, Passos E, Benevides R, organizadores. Pesquisa avaliativa em saúde mental: desenho participativo e efeitos da narratividade. São Paulo: Hucitec; 2008. p. 321-334.^,1212 Onocko-Campos R. Inovações para o estudo e a produção de consensos: além do Delphi. In: Onocko-Campos R, Furtado JP. Desafios de avaliação de programas e serviços em saúde. Campinas, São Paulo: Editora da Unicamp; 2011.. The final version was presented to the entire São Paulo field research group.

Subsequently, the narratives were inserted into interpretative grids and distributed into seven argumentative cores. We selected four to discuss in this article: i) social and subjective aspects during the pandemic: factors that produce subjectivity and healthcare; ii) illnesses associated with the pandemic; iii) client-professional-PHC/SUS relationship: power relations, institutional democracy, management, and healthcare; and iv) potentialities and obstacles to conducting an expanded and shared clinic in PHC.

The analysis was performed from triangulation between the material from the interviews and the researchers’ field diaries and then discussed in light of documents published by SMS-SP and the Paideia framework.

We followed the procedures provided for by resolution No. 466/2012 CNS/MS and complementary procedures. The Ethics Committee of the State University of Campinas and the SMS-SP Ethics Committee approved the research, CAAE: 40699120.2.0000.5404, under Opinion No. 4.520.254.

Results

The workers’ and clients’ narratives point to significant changes in the organization of work at UBS in the city of São Paulo, resulting in losses in care production.

Work management

In March 2020, the UBS received municipal recommendations¹³13 São Paulo. Secretaria Municipal de Saúde. Portaria nº 154, de 20 de março de 2020. Determina a suspensão parcial e temporária de consultas, exames, procedimentos e cirurgias de rotina, a partir de 23 de março de 2020, nos Ambulatórios Hospitalares e na Rede de Atenção Básica. Diário Oficial da União; 2020.^,1414 São Paulo. Secretaria Municipal de Saúde. Portaria nº 182, de 14 de abril de 2020. Altera a Portaria 154/2020-SMS-GAB, que determinou a suspensão parcial e temporária das consultas, exames, procedimentos e cirurgias de rotina, a partir de 23 de março de 2020, nos Ambulatórios Hospitalares e na Rede de Atenção Básica, para dar outras providências. Diário Oficial da União; 2020. to suspend scheduling routine appointments, educational groups, and referrals to specialties and elective surgeries. There was no type of alignment or explanation for workers and clients:

The PHC flow was reorganized to care for people with respiratory symptoms suspected of being infected by COVID-19. This type of care increased exponentially and required the removal of patients, given the severity of the cases:

A progressive reopening of agendas¹⁵15 São Paulo. Secretaria Municipal de Saúde. Portaria nº 260, de 18 de junho de 2020. Altera a determinação de suspensão parcial de consultas, exames, procedimentos, regulamentada pela portaria SMS.G nº 154/2020 e estabelece o retorno gradual aos atendimentos agendados nas UBS, CAPS, URSI, PAI, CEO, EMAD, CER, CECCO e Unidades de Práticas Integrativas e Complementares em conformidade com as normas de biossegurança e distanciamento social até retorno de 100% das atividades conforme o cenário da pandemia COVID 19. Diário Oficial da União; 2020. was observed in the second half of 2020. The guidelines aimed to prioritize care flows for mild respiratory symptoms and focused on prevention and health promotion actions such as individualized guidelines via telemedicine, teleconsulting, and telemonitoring; community management, with health education interventions for the population; keeping flows to separate people with respiratory symptoms from the rest of the population. Moreover, specific services were resumed for some priority groups, such as pregnant and puerperae, children (childcare), people with chronic non-communicable diseases (NCDs) and notifiable diseases, and the extended validity of prescriptions for continuous use medicines (from 2 to 6 months). According to the workers, these guidelines were incorporated by each team heterogeneously and uniquely.

In 2021, with new virus variants, regulations¹⁶16 São Paulo. Secretaria Municipal de Saúde. Portaria nº 117, de 5 de março de 2021. Determina a restrição temporária do atendimento de consultas presenciais, exames, procedimentos, a partir de 08 de março de 2021, na Rede de Atenção Básica e Especializada. Diário Oficial da União; 2021.^,1717 São Paulo. Secretaria Municipal de Saúde. Portaria nº 124, de 17 de março de 2021. Altera a redação da Portaria SMS-G nº 117, de 5 de Março de 2021, que determinou a restrição temporária do atendimento de consultas presenciais, exames, procedimentos, a partir de 08 de março de 2021, na Rede de Atenção Básica e Especializada, quanto à prestação assistencial na Rede de Atenção Especializada. Diário Oficial da União; 2021. resumed the previously imposed restrictions. In parallel, vaccination began in January 2021 with the first dose, and the vaccine was also made available to children at the end of 2022, along with the distribution of the third dose to adults and older adults. Changes and guidance and the publication of guideline documents accompanied epidemiological changes in transmission.

The work process of ACS, who play a fundamental role in the ESF proposal, needed to be more characterized. Besides changes in the home visits, in which ACS could no longer enter families’ homes, ACS began to assist with vaccination, providing administrative support in 2021.

Another process that weakened teams and care was dismantling the NASF proposal. Amid the pandemic, municipal management relocated psychologists and psychiatrists who worked in PHC to establish Mental Health Centers, while the rest of the NASF professionals were allocated to specific units¹⁸18 São Paulo. Coordenadoria de Atenção Básica. Secretaria Municipal de Saúde. Documento Norteador da equipe multiprofissional da atenção básica [Internet]. EMAB; 2023 [acessado 2023 maio 10]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/saude/atencao_basica/index.php?p=340460.
https://www.prefeitura.sp.gov.br/cidade/... :

Care: reflections on the relationship with clients and between workers

Although all units organized the flow of in-person care for people with respiratory symptoms, different forms of restrictions were observed regarding meeting the population’s other demands and needs:

On the other hand, the Street Office had a different guideline, preserving its daily actions and monitoring suspected and confirmed COVID-19 cases via active search, with individual and collective actions in the territory. The team’s work was escalated after SMS imposed weekend shifts.

At the UBS, people seeking care for other health demands and needs also faced the impossibility of coordinating care within the network. Even with the return of appointments, clients noticed changes in how this service was offered:

The professionals interviewed indicated that the reopening of agendas triggered an increase in the number of people with psychological distress and deteriorated NCDs from several changes in psychosocial dynamics introduced by the pandemic, such as social distancing, increased unemployment, and changes in the UBS offerings:

Already disoriented by the variety of guidelines and changes in the organization of the service, workers began to face overload due to their expanded activities, which now include telemonitoring actions, care for mild respiratory symptoms, vaccination within the UBS and in some public places, reception and attending to people’s other health issues with the gradual return of appointments:

Workers’ dismissals, removals, illnesses, and deaths aggravated the shortage of professionals. Also, vacations for healthcare professionals were canceled for a year. The right to removal did not seem equitable, with unequal treatment in case of comorbidity for those in the risk group. The increase in bureaucratic and administrative work in daily work was cited. In their opinion, the confluence of these factors generated the fraying of work relationships between peers, vis-à-vis the employing institution, and even with the population:

Also highlighted was the suffering caused among professionals regarding the fear of becoming ill, given the constant exposure and lack of Personal Protective Equipment (PPE), which also triggered the fear of bringing the disease into their homes. The equipment arrived late, and the workers reported purchasing the PPE with their money:

Professionals engaged in some mobilizations in this substandard work setting, and the most well-organized were those of ACS who publicly protested on the street, demanding better wages and working conditions. However, in early 2022, other professional categories denounced the unhealthy working conditions and demanded improvements through an open letter published by the Health Union¹⁹19 Sindicato dos médicos de São Paulo. Carta aberta dos trabalhadores da saúde atuantes nas Unidades Básicas de Saúde do município de São Paulo - SP - Brasil [Internet]. 2022 [acessado 2023 abr 23]. Disponível em: https://outraspalavras.net/wp-content/uploads/2022/01/Carta-Sindicatos-da-Sau%CC%81de-APS.pdf.
https://outraspalavras.net/wp-content/up... , which generated media repercussions:

The work process of ACS, who play a fundamental role in the ESF proposal, needed to be more characterized. Besides changes in the home visits, in which ACS could no longer enter families’ homes, ACS began to assist with vaccination, providing administrative support in 2021. The changes in the ACS work produced the perception that they needed to provide quality monitoring to users:

The distance between the teams and the community was exacerbated by the re-territorialization process, determined by the municipal management, which consisted of reorganizing the number of registered people to 4,000 people per ESF team. We should mention that this measure was not associated with COVID-19, but overly affected the ACS-territory bond, which is fundamental in confronting the pandemic:

Some clients confirm and resent the weakened link with UBS. They felt abandoned, helpless, and unwelcome during the pandemic, while the fear of infection grew:

Changes in the work process during the pandemic also affected the planning and monitoring of ESF actions due to the need for team meetings, general meetings, and matrix support spaces for discussing cases:

At one of the UBS, at the onset of the pandemic, some professionals tried to keep the meeting space outside, in the open air, to discuss technical guidance documents regarding COVID-19. Another UBS held matrix support meetings via videoconference with CAPS. In both cases, however, we speak of not very comprehensive, non-regular, specific meetings. Even with the resumption of meetings after months of the pandemic, workers report changes in the dynamics of this space:

This range of changes also produced emotional distance between workers, producing significant conflicts during great fear and suffering:

Besides the collective spaces between workers, as a strategic device for the exercise of democracy within health institutions, the Managing Board was also affected. Respondents point to modified meeting formats: sessions were held virtually; they were shorter and less frequent.

The incorporation of new technologies was a legacy of the pandemic. It simultaneously brought challenges and introduced a new working instrument unavailable in PHC. The teams began with telemonitoring suspected cases of COVID-19 to isolate and observe suspected cases and monitor signs of symptom severity. Due to the units’ lack of infrastructure and resources, the teams had to have their resources at the onset of telemonitoring:

Despite the challenges regarding the lack of resources and structure to start telemonitoring and teleconsulting at UBS, most respondents understood that incorporating these resources should become permanent in the teams’ daily lives.

Discussion

The São Paulo PHC management model caused significant repercussions for workers and users of UBS with ESF, as the results demonstrate. We observed a verticalization process of building work and care standards without coordination between municipal management, workers, and the population. The managerialist, Taylorist, and bureaucratic model was maintained during the health emergency. Workers affirm this system was already in place before the COVID-19 pandemic²⁰20 O'Dwyer G, Daumas RP, Cunha DC, Izecksohn MMV. Desafios e repercussões na organização da atenção primária à saúde no contexto da covid-19: o caso do CSEGSF/Teias Manguinhos. In: Portela MC, Reis LGC, Lima, SML. Covid-19: desafios para a organização e repercussões nos sistemas e serviços de saúde. Rio de Janeiro: Observatório Covid-19 Fiocruz; 2022. p. 427-442.. Also, the authoritarian bias in building care is reproduced in the clients’ accounts. The emphasis is on the administrative, management, and care dimensions, with little room for listening and accepting the dilemmas and demands of professionals and, above all, the population.

The suspended team meetings hampered planning actions to monitor the population. They contributed significantly to deconstructing collective work, not only weakening it in its technical dimension but also in its affective role of promoting exchanges and empathy between workers at a time of great suffering, fear, and overload among health workers when such characteristics could have been useful protective measures. The rupture occurred not only in teamwork but in the relationship with the population and social control, with profound impacts also resulting from the modified Managing Board meetings, the canceled activities, and the re-territorialization and deconstruction of the NASF.

The ESF plays a fundamental role during a pandemic that significantly affects the most socially vulnerable population due to its reach and proximity to the population. A “strong PHC”, a term used by PAHO, must assume its surveillance role in screening suspected cases, monitoring cases in the territory, contact tracing, testing, and prevention and health education actions for the population. On the other hand, the results show the lack of this type of PHC strengthening, weakening its potential in epidemiological surveillance in the territory²2 Giovanella L, Franco CM, Almeida, PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.^,2121 Fernandez M, Carvalho W, Borges V, Klitzke D, Tasca R. A Atenção Primária à Saúde e o enfrentamento à pandemia da COVID-19: um mapeamento das experiências brasileiras por meio da Iniciativa APS Forte. APS Rev 2021; 3(3):224-234.^,2222 Giovanella L, Bousquat A, Medina MG, Mendonça MHM, Facchini LA, Tasca R, Nedel FB, Lima JG, Mota PHS, Aquino R. Desafios da atenção básica no enfrentamento da pandemia de covid-19 no SUS. In: Portela MC, Reis LGC, Lima SML. Covid-19: desafios para a organização e repercussões nos sistemas e serviços de saúde. Rio de Janeiro: Observatório Covid-19 Fiocruz; 2022. p. 201-2016.. The fragility and discontinuity of this care were observed in São Paulo, especially for people with chronic diseases²³23 Duarte LS, Shirassu MM, Atobe JH, Moraes MA, Bernal RTI. Continuidade da atenção às doenças crônicas no estado de São Paulo durante a pandemia de Covid-19. Saude Debate 2022; 45(n. esp. 2):68-81.

24 Silva BRG, Corrêa APV, Uehara SCSA. Organização da atenção primária à saúde na pandemia de covid-19: revisão de escopo. Rev Saude Publica 2022; 56:94.^-2525 Engstrom EM, Melo EA, Giovanella L, Pereira AMM, Grabois V, Mendonça MHM. Organização da atenção primária à saúde no SUS no enfrentamento da covid-19. In: Portela MC, Reis LGC, Lima SML. Covid-19: desafios para a organização e repercussões nos sistemas e serviços de saúde. Rio de Janeiro: Observatório Covid-19 Fiocruz, Editora Fiocruz; 2022. p. 185-200..

It is worth noting that these NASF mischaracterizations and re-territorialization occurred in the São Paulo PHC during the pandemic but were aligned with the Federal Government’s policy. Amid a health emergency, family health teams were compelled by Previne Brasil to register 4,000 people, which mobilized re-territorialization. It is an example of bureaucracy-based decision-making, which does not consider the territory’s reality and context and is not taken in shared management with the population and health professionals. The same reasoning applies to dismantling the NASF teams, whose funding was suppressed in the new model, Previne Brasil. Thus, instead of strengthening interdisciplinary work from the perspective of an expanded clinic, which is fundamental for the response to the pandemic, what happened was precisely the opposite²2 Giovanella L, Franco CM, Almeida, PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.^,2626 Silva WRDS, Duarte PO, Felipe DA, Sousa FDOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19 - RJ - Brasil. Trab Educ Saude 2021; 19:2-16.^,2727 Mattos MP, Gutiérrez AC, Campos GWS. Construção do referencial histórico-normativo do Núcleo Ampliado de Saúde da Família. Cien Saude Colet 2022; 27(9):3503-3516..

Although municipal management has made efforts to organize updates to ordinances, we considered that the set of guidelines and training spaces were inadequate since, as suggested by Biscarde et al.²⁸28 Biscarde DGS, Souza EA, Pinto KA, Silva LA, Silva MA, Gusmão MEN. Atenção primária à saúde e covid-19: desafios para universidades, trabalhadores e gestores em saúde. Rev Baiana Enferm 2022; 36:e37824., teams could have received specialized support from management using virtual meetings or video classes through continuing education and matrix support.

Conclusion

The study identified the weakening of PHC attributes in São Paulo: care coordination, longitudinality, comprehensiveness, access, family and community approach, and cultural competency²⁹29 Blanco AS, Astier-Peña MP, Gómez-Bravo R, Fernández-García M, Bueno-Ortiz JM. El papel de la atención primaria en la pandemia COVID-19: Una mirada hacia Europa. Atencion Primaria 2021; 53(8):102134.. This fragilization appears closely linked to a managerialist and bureaucratic PHC management model, which mischaracterizes ESF’s work, approaches an individualistic selective model, and erases crucial aspects of health responsibility towards the enrolled population. Although these weaknesses have been reported in previous studies, their exacerbation was identified here during the pandemic.

The ESF model, historically in dispute in the municipality, added to the performance targets, which have always been present in relationships with the OSS and were later endorsed by Previne Brasil²2 Giovanella L, Franco CM, Almeida, PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.^,3030 Medina MG, Giovanella L, Bousquat A, Mendonça MHMD, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica 2020; 36(8):e00149720.^,3131 Sala A, Luppi CG, Simões O, Marsiglia RG. Integralidade e Atenção Primária à Saúde: avaliação na perspectiva dos usuários de unidades de saúde do município de São Paulo. Saude Soc 2011; 20(4):948-960., emphasize appointments and individual care and seem to relate to precarious work and care, generating harmful effects among workers and users. Even with experiences showing the relevance of enhancing PHC to guarantee all necessary care for the population, this did not become the rule in São Paulo, and such poor conditions mobilized professionals for better working conditions, but with an incipient response²⁰20 O'Dwyer G, Daumas RP, Cunha DC, Izecksohn MMV. Desafios e repercussões na organização da atenção primária à saúde no contexto da covid-19: o caso do CSEGSF/Teias Manguinhos. In: Portela MC, Reis LGC, Lima, SML. Covid-19: desafios para a organização e repercussões nos sistemas e serviços de saúde. Rio de Janeiro: Observatório Covid-19 Fiocruz; 2022. p. 427-442.^,3232 Rufino E, Carneiro Junior N. Caracterização do atributo acesso na Atenção Primária à Saúde nos Contratos de Gestão das Organizações Sociais de Saúde no município de São Paulo. Rev APS 2022; 25(1):22-31..

Thus, we conclude by saying that São Paulo’s municipal management model significantly and adversely affected the construction of care during the COVID-19 pandemic, further weakening and mischaracterizing ESF’s work that was already at an accelerated pace of deconstruction by the municipality and then the Federal Government.

References

Publication Dates

History