Abstract

This study examined the role of community health workers in implementation of primary care actions during the COVID-19 pandemic in the municipality of Peruíbe, São Paulo, Brazil. This is a qualitative case study, guided by the theoretical perspective proposed by Lipsky, according to which street-level bureaucrats play a central role in policy implementation. The research tool was semi-structured interviews of two community health agents, a doctor, a nurse and four local health managers. Analysis of the transcripts identified municipal action in three dimensions to address the health crisis: health system organisation; community health workers’ activities; and restoration of primary health care routines. Community health workers were found to play active roles in the various local measures to combat COVID-19.

Key words:
Community Health Workers; Primary Health Care; COVID-19; Health Human Resources; Pandemics

Introduction

The uncertainties posed by the onset of the COVID-19 pandemic in March 2020 led Brazilian municipalities to take different orders of action at different times. At first, new care flows had to be organised for those infected with the SARS-CoV-2 virus, for extended social distancing measures (or lockdown) to be applied and for case tracking methodologies, prevention measures and campaigns and rapid testing, implemented. Over the course of two years, health managers and personnel also had to reorganise the components of Primary Health Care (PHC) without neglecting care for mild COVID-19, while taking on vaccination and care for people with long COVID-19.

This was no easy task, particularly as Brazil’s municipalities are very diverse in every respect. Also, major differences between the state and federal governments resulted in chaotic health management¹1 Ventura DFL, Perrone-Moisés C, Martin-Chenut K. Pandemia e crimes contra a humanidade: o "caráter desumano" da gestão da catástrofe sanitária no Brasil. Rev Direito Praxis 2021; 12(3):2206-2257.. In this context, studies of public administrations’ local level health actions during the health crisis are important.

Primary care is the main gateway to Brazil’s Unified Health System (Sistema Único de Saúde, SUS), in which care is framed by the Family Health Strategy (Estrategia de Saúde da Família, ESF). Primary health care was considered fundamental in coping with COVID-19, because most cases were mild and could be followed up at this level of care²2 Silva BRG, Corrêa APV, Uehara SCSA. Primary health care organization in the Covid-19 pandemic: scoping review. Rev Saude Publica 2022; 56:94..

In São Paulo, implementation of the ESF, still known as the Family Health Programme, began in 1996 in some areas of the capital and state. In 1999, guided by socioeconomic indicators, the State Health Secretary extended the model to the Vale do Paraíba and Litoral Norte, Vale do Ribeira and Itapeva/Itararé, Oeste Paulista and Pontal do Paranapanema, as well as to rural settlements and quilombola communities. By 2002, despite its receiving technical and financial support, only 5.6 million people (at the time, around 20% of the population of São Paulo State) were covered by family health teams³3 Guedes JS, Santos RMB, Di Lorenzo RAV. A implantação do Programa de Saúde da Família (PSF) no Estado de São Paulo (1995-2002). Saude Soc 2011; 20:875-883.. Twenty years later, coverage had reached 21.9 million (about 47.8% of the population)⁴4 Giovanella L, Bousquat A, Schenkman S, Almeida PF, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.. That performance reflects not only the difficulties inherent to processes of organisational change, but also the different models of primary care coexisting in the state.

Community health workers, whose role is promoting and preventing, building mutual receptiveness based on approachable, affectionate words and actions and forging bonds of trust, commitment and friendship with the public, are fundamental to the ESF. Health and family problems are identified by active listening and dialogue, affective values and respect for others’ lives, based on the collective interest and logic of territories where they work and often live⁵5 Carli RD, Costa MC, Silva EB, Resta DG, Colomé ICS. Welcoming and bonding in the conceptions and practices of community health workers. Texto Contexto Enferm 2014; 23(3):626-632.. Home visits, one tool of the CHW’s work, are made as a matter of routine and organised to meet the demands of public and territory⁴4 Giovanella L, Bousquat A, Schenkman S, Almeida PF, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.. The CHWs’ work was particularly jeopardised impacted during the pandemic by social distancing, a control measure that interfered with home visits. These were thus suspended and later resumed in the format of visits near the home. During this period, health teams had to reinvent and extrapolate their activities, adapting them to the various different stages of the pandemic.

This article based on a case study of Peruíbe (São Paulo state) presents and discusses the CHWs’ role in primary health care offered during the COVID-19 pandemic.

Methodology notes

In this study, the service site and bureaucrats play central roles in public policy implementation processes. In that regard, the day-to-day realities of government action are frame by the interaction between frontline service agents and the public, as well as the characteristics of the location, the distances between services and residences and/or workplaces, and the local population’s health needs, as well as other factors. Spink and Burgos⁶6 Spink P, Burgos F. Os limites da abordagem de implementação: vulnerabilidade urbana a partir do outro lado da rua. In: Lotta G, organizadora. Teoria e análises sobre implantação de políticas públicas no Brasil. Brasília: Enap; 2019. p. 99-125. write “governments can run programmes on a wide range of issues to improve overall conditions, but the outcomes always occur in places; the ideas and measures will always be applied by someone, somewhere”⁶6 Spink P, Burgos F. Os limites da abordagem de implementação: vulnerabilidade urbana a partir do outro lado da rua. In: Lotta G, organizadora. Teoria e análises sobre implantação de políticas públicas no Brasil. Brasília: Enap; 2019. p. 99-125.(p.108, emphasis added).

The study also drew on the theories of Lipsky⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158., who calls frontline public service personnel “street-level bureaucrats” (SLBs). To Lipsky, when these agents interpret guidelines, they also make assessments and use discretionary freedom to shape the services provided to the public. Lotta and Costa⁸8 Lotta G, Costa MIS. Uso de categorizações políticas e sociais na implementação de políticas: contribuições teóricas e analíticas. Rev Sociol Polit 2020; 28:e004. note that on, a day-to-day basis, SLBs act as connecting links between users and the State.

During the public health crisis, SLBs were acknowledged to be essential. Lotta et al.⁹9 Lotta G, Nunes J, Fernandez M, Garcia Correa M. The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers. Health Policy OPEN 2022; 3:100065. note that CHWs heightened the possibility of meeting the challenges of the pandemic, given that they worked to monitor symptoms, collect epidemiological data and refer cases to specialised services. Ballard et al.¹⁰10 Ballard M, Johnson A, Mwanza I, Ngwira H, Schechter J, Odera M, Mbewe DN, Moenga R, Muyingo P, Jalloh R, Wabwire J, Gichaga A, Choudhury N, Maru D, Keronyai P, Westgate C, Sapkota S, Olsen HE, Muther K, Rapp S, Raghavan M, Lipman-White K, French M, Napier H, Nepomnyashchiy L. Community Health Workers in Pandemics: Evidence and Investment Implications. Glob Health Sci Pract 2022; 10(2):e2100648. corroborate this in their discussion of the role of community health workers in COVID-19, pointing out that they have played a fundamental role for years in preventing, detecting and responding to epidemics in many countries’ health systems and have been fundamental to local responses to those events. Peretz et al.¹¹11 Peretz PJ, Islam N, Matiz LA. Community Health Workers and COVID-19 - Addressing Social Determinants of Health in Times of Crisis and Beyond. N Engl J Med Overseas Ed 2020; 383(19):e108., for example, report how, at the New York Presbyterian Hospital and the Grossman School of Medicine, CHWs acted during the pandemic as cultural intermediaries between the community and health systems, mitigating fear, correcting misinformation among the most vulnerable, identifying and addressing social determinant-related issues that affected COVID-19 prevention and treatment. It is thus evident that CHWs were part of countries’ public health response to the pandemic.

The assumption that public measures are not implemented by some mechanised process and that SLBs are central figures does not mean that public policies, laws and programmes are unimportant. On the contrary, as Lima and D’Ascenzi¹²12 Lima LL, D'Ascenzi L. Implementação de políticas públicas: perspectivas analíticas. Rev Sociol Polit. 2013; 21:101-110. emphasise, such documents also affect how action is implemented, because they give the legal and institutional framework that specifies the arenas of action, the tools, the roles of the various actors and how resources are allocated and distributed. That is why this study referred to certain documents to understand the guidelines that framed CHWs’ actions in Peruíbe.

This study used data from the qualitative stage of the survey “Primary Health Care Policy in the pandemic context in municipalities of São Paulo”, by the Instituto de Saúde (IS), an agency of the São Paulo state department of health (Opinion No. 4.842.154 of the IS research ethics committee). In the second half of 2022, 37 people from six municipalities, selected from the survey produced in the quantitative stage, were interviewed face-to-face. The semi-structured interviews followed a guiding script about local PHC organisation during the public health crisis. Participation was voluntary, after signing a declaration of free and informed consent, and participants were free to answer questions or not and to introduce other topics. The interviews were recorded, transcribed and read in full.

The methodological strategy used was the Peruíbe case study, which made it possible to discuss the role of CHWs in combating COVID-19. That approach afforded an in-depth understanding of the complexity of certain situations by detailing and contextualising the phenomenon¹³13 Yin RK. Pesquisa Estudo de Caso - Desenho e Métodos. 2ª ed. Porto Alegre: Bookman; 1994.. The municipality of Peruíbe was chosen, because analysis of the interviews identified this theme in the discourse of several staff members. Also, as it is a tourist destination, local management deals daily with the challenges of a seasonal population and, since the onset of the pandemic, had absorbed a large number of people from other cities working remotely, which entailed complexities for the work of PHC and new SUS user registrations.

Eight interviews were conducted in the town, of four street-level bureaucrats, two community health workers (CHW1 and CHW2), a doctor (P1) and a nurse (P2), as well as four managers at different levels (G1, G2, G3, G4). It was thus possible to describe the main actions taken during the pandemic and to identify the CHWs’ role, which emerged transversely in the interviewees’ discourse. That is, although the original script did not contain any specific question on the topic, it permeated the interviews, allowing us, on a discursive practice approach, to circumscribe the interpretative repertoires associated with the CHW’s work as an object of analysis¹⁴14 Spink MJP, Medrado B. Produção de sentidos no cotidiano: uma abordagem teórico-metodológica para análise das práticas discursivas. In Spink MJP, organizador. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. São Paulo: Cortez; 1999. p. 41-62..

This article focuses on information on the way Peruíbe organised primary health care during the pandemic, as well as on the repertoires that participants deployed to describe the CHWs’ function. Interpretive repertoires are linguistic devices comprising terms, descriptions, commonplaces and figures of speech that demarcate the list of possibilities in the production of meaning, according to the dynamics, variability and polysemy of social relations¹⁴14 Spink MJP, Medrado B. Produção de sentidos no cotidiano: uma abordagem teórico-metodológica para análise das práticas discursivas. In Spink MJP, organizador. Práticas discursivas e produção de sentidos no cotidiano: aproximações teóricas e metodológicas. São Paulo: Cortez; 1999. p. 41-62.. As the focus of analysis, they also help to identify how we position ourselves and our interlocutors, and to perceive the versions of reality produced by people, groups or society¹⁵15 Aragaki SS, Piani PP, Spink MJ. Uso de repertórios linguísticos em pesquisas. In: Spink MJP, Brigagão JIM, Nascimento VLV, Cordeiro MP. A produção de informação na pesquisa social: compartilhando ferramentas. Rio de Janeiro: Centro Edelstein de Pesquisas Sociais; 2014.. This was complemented by using the interviewer’s field diary and texts from documents in the public domain (municipal laws and decrees and press reports).

The main limitations are, first, that the research script was prepared to study the organization of primary health care in the municipality and not with regard to CHWs’ role in the pandemic and, second, the number of participants. It is thus important that further research investigate community health workers’ role in COVID-19, which this study demonstrated to be fundamental in PHC. It is also important to invest in qualitative research on PHC in the public health crisis.

Social and political context

Peruíbe is in the Baixada Santista metropolitan region, 140 km from the state capital, São Paulo. Covering 326.216 km² and with a population of 68,344, it has a population density of 209.51/km² and a municipal human development index of 0.749, which is considered high¹⁶16 Instituto Brasileiro de Geografia e Estatística (IBGE). Panorama Censo 2022 [Internet]. Rio de Janeiro: IBGE; 2023 [acessado 2023 jul 13]. Disponível em: http://censo2022.ibge.br/panorama..

The local health system includes 12 family health facilities and a “health academy”, as well as a general hospital, which also has a maternity unit, a medical speciality outpatient clinic and two psychosocial care centres, one of them for children. A survey in September 2022 found the town had 73 CHWs¹⁷17 TabNet Win32 3.0. CNES - Recursos Humanos - Profissionais - Indivíduos - segundo CBO 2002 - São Paulo [Internet]. 2023 [acessado 2023 abr 28]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?cnes/cnv/prid02sp.def.
http://tabnet.datasus.gov.br/cgi/tabcgi.... and PHC population coverage of 92.38%¹⁸18 e-Gestor AB [Internet]. [acessado 2023 abr 27]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastro.xhtml;jsessionid=WjdknCzWGij7HIb6asaF5ztO.
https://egestorab.saude.gov.br/paginas/a... .

Since the SUS was instituted, health policies have been induced by the federal government, which formulates and coordinates intergovernmental action at the subnational and local levels¹⁹19 Arretche M. Democracia, federalismo e centralização no Brasil. Rio de Janeiro: FVG, Fiocruz; 2012.. With the health crisis, however, many states and municipalities diverged from federal proposals for combating COVID-19 and, breaking with that model, applied specific policies. Friction between the national and subnational entities emerged at several points regarding how to tackle the pandemic, notably around the former president’s resistance to social distancing measures and his incessant discrediting of scientific evidence in favour of denialism and political and economic interests. These divergences can be explained by reference to his address to the nation, on March 26, 2020:

In that context, the Executive published Provisional Order No. 923/2020, of Law No. 13,979/2020, which concentrated the identification and regulation of essential activities in the person of the president. That order was then challenged, on April 15, by a Direct Action of Unconstitutionality, ADI No. 6,341, leading the Federal Supreme Court, on constitutional principles, to establish the concurrent competence of the federal district, states and municipalities in combating the pandemic and to acknowledge the power of local managers to apply specific policies for the crisis²¹21 Supremo Tribunal Federal. STF reconhece competência concorrente de estados, DF, municípios e União no combate à COVID-19 [Internet]. 2020 [acessado 2023 abr 28]. Disponível em: https://portal.stf.jus.br/noticias/verNoticiaDetalhe.asp?idConteudo=441447&ori=.
https://portal.stf.jus.br/noticias/verNo... .

In the early months of the pandemic, the São Paulo government published decrees imposing quarantine, and, on May 28, 2020, it introduced the São Paulo Plan (Decree No. 64,994)²²22 São Paulo. Decreto no 64.994, de 28 de maio de 2020 [Internet]. [acessado 2023 abr 27]. Disponível em: https://www.al.sp.gov.br/leis/legislacao-do-estado/.
https://www.al.sp.gov.br/leis/legislacao... , which provided for phased easing of social distancing.

Peruíbe and nine other municipalities make up the Baixada Santista Metropolitan Region Development Council (Condesb), where mayors make collective decisions on COVID-19 control in the local regional. On December 23, 2020, the Condesb decided that the region would remain on yellow alert, at odds with the São Paulo State Coronavirus Contingency Centre, which had placed the entire territory of São Paulo on red alert, from 25 to 27 December 2020, and 1 to 3 January 2021²³23 G1. Prefeitos decidem manter litoral de SP na fase amarela e fechar as praias no Réveillon | Santos e Região [Internet]. [acessado 2023 abr 27]. Disponível em: https://g1.globo.com/sp/santos-regiao/noticia/2020/12/23/prefeitos-decidem-manter-litoral-de-sp-na-fase-amarela-e-fechar-as-praias-no-reveillon.ghtml.
https://g1.globo.com/sp/santos-regiao/no... . The mayors’ argument was that there was not enough time to take such a measure and that it was more important to block the beaches during New Year’s Eve. They also requested the state government place health barriers on the Baixada access roads, so as to prevent the influx of tourists. On 25 January, 2021, following a consensus decision by the Condesb due to the mounting numbers of COVID-19 cases, hospitalisations and deaths, Peruíbe decided to follow the São Paulo Plan completely: at the time, the recommendation was for “orange alert, with red alert restricted on weekdays, after 8 p.m., and full at weekends”²⁴24 Mais Peruibe. Fase Vermelha - Peruíbe terá praias com restrições em atendimento ao decreto estadual [Internet]. 2021 [acessado 2023 abr 27]. Disponível em: https://www.maisperuibe.com.br/2021/01/fase-vermelha-peruibe-tera-praias-fechadas-em-atendimento-ao-decreto-estadual/.
https://www.maisperuibe.com.br/2021/01/f... . That is, the municipalities did not adhere automatically to the state plan, but rather made a joint assessment of the local situation, the multiple dimensions entailed by the measures and autonomous decisions at different times during the pandemic.

The organization of the local health system during the pandemic

To guarantee health care and control the number of those infected with SARS-CoV-2, Peruíbe set up a new flow of care and referral for suspected and confirmed cases, using a new monitoring and tracking methodology. In the early months of the pandemic, the main gateway for direct care for symptomatic flu-like illness was the medical speciality outpatient clinic, which screened cases and referred them to the emergency unit, as necessary.

In an effort to improve communication and assist the public in preventing and combating the spread of the disease, the municipal health department set up a COVID-19 care centre, comprising an epidemiological surveillance function and workers from the PHC system. Open from Monday to Friday, 8:00 a.m. to 5:00 p.m., it provided guidance to the public on the main doubts relating to the disease: how and when to access the PHC facility, the emergency unit or stay at home and watch the symptoms:

Together with the epidemiological surveillance, it also monitored reported cases and their families. Notification triggered the work process at the centre:

At the start of the crisis, the municipal government suspended many routine PHC activities. But on 18 June 2020, the municipal executive published Decree No. 4,956²⁵25 Peruíbe. Decreto nº 4.956, de 18 de junho de 2020 [Internet]. [acessado 2023 abr 28]. Disponível em: https://leismunicipais.com.br/a/sp/p/peruibe/decreto/2020/496/4956/decreto-n-4956-2020-dispoe-sobre-a-retomada-dos-servicos-na-administracao-publica-municipal.
https://leismunicipais.com.br/a/sp/p/per... , with rules for the return of PHC services and new flow arrangements for COVID-19 cases:

That is, two flows were set up for access to PHC units, one for COVID-19 symptomatic cases and another for other demands:

This strategy aligns with what has been observed by a number of authors who, from the outset, understanding primary health care to be the proper place to address COVID-19, argued that it was fundamental to use its resources and knowledge of the territory, as well as the bonds already forged with the local population. In that way, it would be possible to monitor all cases and treat people with mild symptoms²⁶26 Daumas RP, Silva GA, Tasca R, Leite IC, Brasil P, Greco DB, Grabois V, Campos GWS. O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da COVID-19. Cad Saude Publica 2020; 36:e00104120.

27 Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica 2020; 36:e00149720.^-2828 Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saude 2020; 29:e2020166.. In that light, for managers, PHC took the leading role in the pandemic, with CHWs playing a fundamental role in the actions:

Note that Lipsky⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158. points out: “Finally, goal conflicts and ambiguity arise from the contradictory expectations that shape the street-level bureaucracy role”⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158.(p.113). Thus, despite the accounts of managers and other personnel indicating that there were no conflicts with the team over CHWs’ functions during the pandemic, it has to be said that it was not always a smooth relationship. At the onset of the crisis, some resisted working at the front line:

In Peruíbe, despite the health teams’ efforts, many users regularly monitored by the PHC were lost, because COVID-19 cases had to be prioritised and people often avoided health services for fear of contagion. Also, the physical premises of the primary health care service could not accommodate a large number of people, because of social distancing guidelines. Another difficulty pointed to was the increase in the population to be served in the municipality, as already mentioned, due to the seasonal population working remotely, with no increase in funding, as reported by G1:

Accordingly, the CHWs’ workload increased during the pandemic, because they were the ones who had to make the entries.

The interviewees reported internal routine that included constant training and meetings to align all procedures and give teams access to new evidence-based COVID-19 care protocols. Channels were also created to spread updated information, such as new guidelines, new clinical care protocols and memoranda to optimise communication within the teams:

Because it is a new disease, COVID-19 generated a lot of disinformation and denialism. The SLBs from Peruíbe, such as P1, P2 and CHW2, recognised the importance of scientific support for management’s proposals and the effort to ensure communication within the teams, as well as their providing training, capacity-building and guidelines for action. In that respect, Lipsky⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158. notes: “Administrators and occupational and community norms also structure policy choices of street-level bureaucrats”(p.56). To him, this does not prevent SLBs from exercising discretion in their area of activity: “even public employees who do not have claims to professional status exercise considerable discretion”⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158.(p.56).

The next section will discuss how the CHW’s, with their discretionary power and guided by the knowledge built up in their close relationships with their public, were important in addressing the public health crisis in Peruíbe.

The CHWs’ activities in the pandemic

Social distancing recommendations led to the introduction of other functions for CHWs and involved them in the work to contain the spread of the virus²⁹29 Brasil. Secretaria de Atenção Primária à Saúde (SAPS). Recomendações para adequação das ações dos Agentes Comunitários de Saúde frente à atual situação epidemiológica referente ao COVID-19 [Internet]. Brasília; 2020 [acessado 2023 abr 28]. Disponível em: https://www.conasems.org.br/wp-content/uploads/2020/04/20200403_recomendacoes_ACS_COVID19_ver002_final_b.pdf.
https://www.conasems.org.br/wp-content/u... . Despite protocols and guidelines, CHWs establish a complex relationship with the population that requires them to make discretionary decisions and interventions in the day-to-day work of health promotion. Lipsky⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158. writes:

In Peruíbe, it could be seen that, during the pandemic, CHWs maintained some routine activities, such as registration of new residents. However, a number of changes in routine led these workers to work in providing guidance to reduce contamination, monitoring cases of COVID-19 and observing for signs of other diseases worsening, because they dealt routinely with chronically ill people, such as diabetics and hypertensives, as well as pregnant women and older adults. This enabled them to learn of problems connected with these diseases. CHWs also used active listening in telephone calls and peridomiciliary visits in order to take therapeutic action.

Telephone monitoring was very important to ensure that people diagnosed with COVID-19 could dispel their doubts and be instructed to seek health services if symptoms worsened. In that regard, it is difficult to measure CHWs’ actions, because SLBs’ activities depend on many variables, often preventing effective evaluation. As Lipsky⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158. put it: “It is not only that human beings are complex and that a metric of correct responses is inappropriate. Equally important, there is rarely any way to determine on a regular basis what would have happened to clients in the absence of intervention”⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158.(p.118). One interview excerpt expressed this complexity:

What is certain is that the bonds of trust forged in regular monitoring of the public before the pandemic did favour screening and monitoring of COVID-19 cases:

In the CHWs’ daily routine, attentive listening, participant observation and bonding are work tools that make therapeutic care actions possible whenever there is interaction:

In these excerpts the SLBs’ discretionary freedom is evident⁷7 Lipsky M. Burocracia de nível de rua: dilemas do indivíduo nos serviços público [Internet]. Brasília: Enap; 2019 [acessado 2023 abr 12]. Disponível em: https://repositorio.enap.gov.br/handle/1/4158.^,88 Lotta G, Costa MIS. Uso de categorizações políticas e sociais na implementação de políticas: contribuições teóricas e analíticas. Rev Sociol Polit 2020; 28:e004.; it allows them to decide to prioritise certain patients and devote more time to those who need more attention. Another dimension brought out here is the CHWs’ ability to connect with the community, which was also highlighted by Peretz et al.¹¹11 Peretz PJ, Islam N, Matiz LA. Community Health Workers and COVID-19 - Addressing Social Determinants of Health in Times of Crisis and Beyond. N Engl J Med Overseas Ed 2020; 383(19):e108.:

Returning to the PHC routine

In the first three months of the pandemic, routine home visits were suspended, restricted to specific cases and active detection following COVID-19 notifications. As already said, Decree No. 4,956/2020²⁵25 Peruíbe. Decreto nº 4.956, de 18 de junho de 2020 [Internet]. [acessado 2023 abr 28]. Disponível em: https://leismunicipais.com.br/a/sp/p/peruibe/decreto/2020/496/4956/decreto-n-4956-2020-dispoe-sobre-a-retomada-dos-servicos-na-administracao-publica-municipal.
https://leismunicipais.com.br/a/sp/p/per... instructed visits to be resumed in settings near homes, in order to guarantee the safety of both the public and health personnel. This study found PHC being adapted in a gradual process in response to the successive stages of the pandemic. For example, health promotion groups, one of the regular collective activities that CHWs took part in and/or coordinated, had been suspended at the start of the crisis to avoid gatherings. In some territories, however, these were quickly restored, as soon as distancing measures were relaxed:

CHW1’s words show that, although health promotion, which takes place during home visits, has historically been central to the work of community health workers, because it helps teams to provide comprehensive care, it is necessary to go beyond that dimension:

It is fundamental that managers at all levels recognise that these professionals’ importance goes beyond health promotion. They must be recognised as allies in the fight against the dismantling of the Family Health Strategy, which is explicit in the 2017 National Primary Care Policy. That policy makes far-reaching changes to the CHWs’ role, by removing the requirement of a minimum number of CHWs in family health teams and recommending that those who remain perform nursing duties, thus reinforcing a biomedical rationale and breaking with the health promotion model³⁰30 Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate 2018; 42:261-274..

Final remarks

Administrative policy decisions were very important to controlling the pandemic in Brazil and framed guidelines at the various levels of management of the Unified Health System. However, it has to be recognised it was street-level bureaucrats who were responsible for giving material form to measures from day to day in health care services. The study showed that community agents were fundamental to PHC activities to address the public health crisis caused by COVID-19. In the municipality of Peruíbe, these personnel played an active part in prevention, tracking, monitoring and care offered to the local population.

In the frontline of health work, especially at the most acutely critical points, SLBs make decisions and choices that impact the population. That is why it is important to ensure capacity-building and training, so that those choices are guided by scientific evidence and help to extend the reach of multidisciplinary teams.

The CHWs’ knowledge of the territory and their ability to connect with the community greatly facilitated the various health promotion activities they engaged during and after the pandemic. The study showed that there are CHWs who manage to play their role with reflective empathy and attentive listening to demands, which makes it possible to inform the health teams and provide the population with comprehensive care. In that regard, from the experience of Peruíbe, these personnel can be said to be fundamental to PHC, not only in day-to-day service activities and control of health crises. They are fundamental to restoring a national primary health care policy aligned with the fundamental and organisational principles of the SUS.

References

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