What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020

Chaves, Ana Cláudia Cardozo; Scherer, Magda Duarte dos Anjos; Conill, Eleonor Minho

doi:10.1590/1413-81232023289.15342022

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REVIEW • Ciênc. saúde coletiva 28 (09) 04 Sept 2023Sept 2023 • https://doi.org/10.1590/1413-81232023289.15342022EN copy

What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020

About the authors

Abstract

Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term “resolvability”, commonly used in Brazil, for “effectiveness”.

Key words:
Primary Health Care; Effectiveness

Introduction

Healthcare systems are a historical, economic, political and cultural setting. Although healthcare services are only part of these systems, their performance embase practices and public policies analyses¹1 Viacava F, Almeida C, Caetano R, Fausto M, Macinko J, Martins M, Noronha JC, Novaes HMD, Oliveira ES, Porto SM, Silva LMV, Szwarcwald CL. Uma metodologia de avaliac¸a~o do desempenho do sistema de sau´de brasileiro. Cien Saude Colet 2004; 9(3):711-724.^,²2 Tyrovolas S, Polychronopoulos E, Tountas Y, Panagiotakos D. The role of health care systems on populations' health status and longevity: A comprehensive analysis. Health Sci J 2010; 4(3):149-156..

Primary Health Care (PHC) intends to rearrange services to make it more effective³3 Giovanella L, Mendonça MHM, Buss PM, Fleury S, Gadelha CAG, Galvão LAC, Santos RF. De Alma-Ata a Astana. Atenc¸a~o prima´ria a` sau´de e sistemas universais de sau´de: compromisso indissocia´vel e direito humano fundamental. Cad Saude Publica 2019; 35(3):e00012219.. Practices guided by PHC are expected to meet most of community needs enabling timely access to continued and high-quality health, with the right technologies to avoid unnecessary interventions⁴4 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco/MS; 2002.^,⁵5 Almeida PF, Fausto MCR, Giovanella L. Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Rev Panam Salud Publica 2011; 29(2):84-95..

However, in many countries, PHC is different from that with disparities between what individuals and communities need and the quality of services, with standardized services for a small part of the population⁶6 Bitton A, Ratcliffe HL, Veillard JH, Kress DH, Barkley S, Kimball M, Secci F, Wong E, Basu L, Taylor C, Bayona J, Wang H, Lagomarsino G, Hirschhorn LR. Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries. J Gen Intern Med 2017; 32(5):566-571.

7 Brandão JRM. A atenc¸a~o prima´ria a` sau´de no Canada´: realidade e desafios atuais. Cad Saude Publica 2019; 35(J):e00178217.^-⁸8 Brasil. Portaria de Consolidação nº 2, de 28 de setembro de 2017. Política Nacional de Atenção Básica. Anexo XXII. Diário Oficial da União 2017; 28 set.. In Brazil, even though there is a universal health system with PHC as a structural policy⁸8 Brasil. Portaria de Consolidação nº 2, de 28 de setembro de 2017. Política Nacional de Atenção Básica. Anexo XXII. Diário Oficial da União 2017; 28 set., we found selective practices and fragmented care⁹9 Conill EM. Análisis de la problemática de la integración de la APS en el contexto actual: causas que inciden en la fragmentación de servicios y sus efectos en la cohesión social. Intercambio III 2-1-2007. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca/Fiocruz; 2007.^,¹⁰10 Facchini L, Tomasi E, Thumé E. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021..

Nevertheless, effectiveness in PHC is quite a challenge. In Brazil, the National Primary Health Care Policy (Política Nacional de Atenção Básica - PNAB)⁸8 Brasil. Portaria de Consolidação nº 2, de 28 de setembro de 2017. Política Nacional de Atenção Básica. Anexo XXII. Diário Oficial da União 2017; 28 set. established it as a goal and the National Health Plan 2020-2023 considered it an strategic objective “to promote the expansion of PHC services in a integrated and planned manner” to be achieved by the performance of 20 indicators¹¹11 Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020..

Effectiveness is a complex political commitment because it depends on several demographic, epidemiological and sociocultural variables which determine health conditions. There is a wide range of needs often in adverse sociopolitical contexts which challenges the services capacities. Moreover there is a conceptual and orthographic polysemy around effectiveness ranging from a health policy goal to an evaluation tool¹²12 D´Aguiar JMM. O Programa Saúde da Família no Brasil. A resolutividade do PSF no município de Volta Redonda (RJ) [dissertação]. Rio de Janeiro: ENSP-Fiocruz; 2001.. This study presents an overview of the literature contributions about PHC effectiveness because mapping the problem is the first step towards facing it.

Methodology

This study used the integrative review¹³13 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidência na saúde e na enfermagem. Texto Context Enferm 2008; 17(4):758-764. method and the PRISMA¹⁴14 Page MJ, Mckenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71. methodology. It started with the guiding question: “what theoretical-methodological contributions are presented in scientific literature to improve PHC effectiveness?” The criteria for inclusion and exclusion, the keywords and databases for search were defined. The study included original articles from indexed journals in English, Spanish and Portuguese, published between February 2010 and February 2020, with the search words in the title and/or abstract. Review studies were excluded as well as guidelines, meetings presentations, courses, speeches and management reports.

The key words came from the Descriptors in Health Sciences (DeCS) and the Medical Subject Headings (MeSH), complemented by the Boolean operators “OR” and “AND”. Due to the absence of a term to translate the exact Portuguese concept of “resolvability” for the international literature in evaluation, we used effectiveness with the follow key words: “resolubilidade”; effectiveness OR effectividad OR efetividade; primary health care OR atención primaria de salud OR atenção primária à saúde. PHC related terms such as general practitioner (Europe, North America), community/local/rural health (Asia, Africa) and atenção básica - AB (Brazil) were considered.

The research was done from February 1^st to 4^th, 2020 at PubMed® and the Virtual Health Library (BVS, in Portuguese), that includes LILACS, MEDLINE, BDENF and IBECS databases. Three reviewers performed the screening of 8,369 studies. The inclusion/exclusion criteria, removal of duplicates, reading of titles and abstracts reduced the number of studies to 1,679. From those, 191 studies were removed because their focus was cost-effectiveness and 1,375 clinical effectiveness, which did not allow inferences regarding the PHC practices and policies in general. After a complete reading of the remaining 113 articles, 23 were excluded leaving a total of 90 selected articles (Figure 1) classified by title, author, year, database, journal and place of origin of the study for thematic analysis by the Atlas.ti® software, version 9.0 (Figure 2).

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Figure 1
Methodological process for studies' selection in the integrative review.

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Figure 2
Network of categories and codes.

To establish the analytical categories, it was considered that models are reality simplifications or idealizations to explain or systematize a phenomenon hypothetically or paradigmatically¹⁶16 Silva FS, Catelli F. Os modelos na ciência: traços da evolução histórico-epistemológica. Rev Bras Ensino Fis 2019; 41:4.. Monitoring and evaluation strategies are activities for follow-up and information analysis regarding services effects for decision-making¹⁷17 Souza MF. Conceitos básicos em monitoramento e avaliação [aula]. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2013.. Technologies transform a given object in the context of a labor process¹⁸18 Pereira IB. Dicionário da educação profissional em saúde. 2ª ed. Rio de Janeiro: EPSJV; 2008.. Organizational arrangements are ways to promote changes in the services and establish levels of care to help the supply management¹⁹19 Freitas MA. Arranjos organizativos da atenc¸a~o primária nas regio~es de sau´de de um Departamento Regional de Sau´de [dissertação]. Ribeira~o Preto: Universidade de Sa~o Paulo; 2017..

Results

There were studies published in all of the years analyzed, especially 2018 and 2012 (18 e 14 articles, respectively). From the 90 articles selected, 50 were from BVS and 40 from PubMed®. Quantitative approaches were predominant (52) followed by qualitative (32) and mixed methods (06).

In terms of language, 69 of the studies were in English, 15 in Portuguese and 6 in Spanish. Concerning the place of origin, South America had 31 articles, 26 of which were from Brazil. There were 23 from Europe, 19 from North America, 6 from Asia, 4 from Africa, 3 from Oceania, and 4 conducted in more than one country. Chart 1 shows the complete list of references of the selected studies, as well as their place of origin.

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Chart 1
Studies selected for review.

There were four categories identified by thematic analysis: strategies for PHC quality monitoring and services evaluation (34 studies), organizational arrangements (25 studies), models (17 studies) and technologies applied to PHC (14 studies). Chart 2 synthesizes the main content found in these studies.

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Chart 2
Selected studies by thematic categories and subthemes.

Strategies for PHC quality monitoring and services evaluation

The indicator ‘Emergency/hospital admissions for PHC Sensitive Conditions’ which appeared mostly in Brazilian studies, was indicated as adequate for quality evaluation with certain limitations. Emergency/hospital admissions are inversely proportional to PHC teams availability (ID 71; 74; 42; 80; 78; 16; 58; 47; 33). However, that indicator can by itself be insufficient to evaluate PHC and requires additional measures of care effectiveness (ID 10; 60). One alternative would be to choose conditions/diseases based on sensitivity and specificity instead of frequency, considering geographic and sociodemographic characteristics, model of care, labor processes and management at the health centers (ID 06).

Brazil and Argentina applied the Primary Care Assessment Tool (PCATool) (ID 32; 64) to evaluate ‘PHC attributes’ as a standard quality measure. South Africa applied a combination of the Nominal Group Technique (NGT) and the PCATool (ID 67) for the same purpose. In 11 countries, the Commonwealth Fund International Health Policy Survey (CFIHPS) was used to analyze care coordination (ID 54). An established relationship with a primary care physician was significantly associated with better care coordination, whereas being chronically ill or younger was associated with poorer care coordination.

“Institutional Assessment Programs” contribute to improve effectiveness. Fifty six indicators of The Swiss Primary Health Care Active Monitoring Program in Switzerland (ID 56) show a decrease in mortality. In England, 20 indicators from the pay-for-performance program of the Public Health Impact create an effectiveness score for PHC (ID 29). The European Practice Assessment in Switzerland (ID 43) points to ímprovements in quality and safety, information and finances. In Germany (ID 09), the same tool points to improvements only in quality and safety. The Estratégia de Evaluación Reformulada para Latinoamérica (Reformulated Evaluation Strategy for Latin America) was appropriate to evaluate performance in all of the subsystems in Argentina (ID 05). The Change Process Capability Questionnaire Strategies Score from the USA revealed heterogeneity of quality improvement strategies applied to PHC centers, making it difficult to standardize the performance evaluation (ID 72). In Brazil, the Health Services Performance Assessment Methodology (PROADESS, in Portuguese) found heterogeneity in effectiveness, access, efficiency and appropriateness subdimensions, with considerable improvements in geographic areas with PHC (ID 17). The Agreements for PHC and for Healthcare led, in general, to improvements in process and results indicators (ID 20). The National Program for Access and Quality in Primary Care (PMAQ-AB, in Portuguese) found better results in first contact and comprehensiveness attributes, and worse in longitudinal care and coordination (ID 73). There were improvements in teamwork and data management, regardless of limitations due to overload and the large amount of data to be collected. There also were difficulties to share results throughout the teams (ID 82). Performance effectiveness does not guarantee outputs and outcomes (ID 59).

Organizational arrangements

“Multidisciplinary teams” with expanded roles, new protagonists and new competencies have proven to be useful (ID 63), especially in contexts with shortage of doctors (ID 65). The implication of all professionals optimizes work and frees up others for tasks that only they can perform. Hence, a larger number of doctors at PHC improves results in health (ID 62). In a Brazilian study (ID 37), effectiveness was related to multidisciplinary teams that produce bonds of trust and autonomy at the workplace.

Nurses stand out for their effectiveness in managing demands, health education and a comprehensive range of needs. (ID 51). Their community, organizational and services performance is highlighted, improving access and the use of other levels of care, as well as doctor’s acceptance of nurses’ clinical competence. (ID 38). Longitudinal care at nurses’ work was also related to improvements in population’s quality of life and in effectiveness within PHC (ID 11).

One study from England (ID 75) suggests that including Community Health Agents on a national scale is recommended/advisable and it can be fastly implemented to help relieve work overload within healthcare services (ID 75). In the USA, teams recognized PHC Community Health Agents effectiveness in solving problems (ID 46).

Concerning “Services organization”, extended hours at night and/or weekends reduced the use at other levels of care in the first 12 months (ID 52), with possible benefits for young patients who work full time (ID 45).

“Rural Health Clinics” experience in the USA (ID 14) revealed that larger clinics are more efficient, suggesting that smaller ones should gather integrated systems or districts (ID 23). In England, the size of PHC units was not decisive for the teams performance and the variance can be explained by population characteristics. Organizational arrangements focused on responsibilities and not merely on the size of population are recommended (ID 18).

The Family Health Strategy in Brazil (ESF, in Portuguese) stands out amongst “Structuring strategies”: wide health services supply and comprehensiveness (ID 53), PHC expansion and strong governance were associated with a decrease in preventable mortality (ID 55). It was considered the best strategy for a strong PHC, when associated with policies that reinforce its attributes with innovations in management of care and communication technologies (ID 90). However, poor diagnostic and therapeutic supply are still challenges for effectiveness and user’s satisfaction (ID 53).

Models

The “Models” category grouped frameworks to increase effectiveness, predominating those concerning the influence of payment in PHC quality. Payment for population basis in Hawaii (ID 84) resulted in reduction of appointments demand, with no significant increase in costs. An European study (ID 57) concluded higher PHC responsiveness happens when doctors are paid by capitation than when they only receive fee-for-services or a mixed payment method.

“Payment for performance”, according to studies from the Netherlands and United Kingdom (ID 24; 31), may improve clinical quality, patients’ experience and care organization. But proved not to be cost effective in another study from the United Kingdom (ID 68), which recommended a redesign of the program or alternative interventions.

Regarding “fee-for-service”, studies from the USA (ID 48; 79) on a model of direct Primary Care concluded that fees improved PHC attributes. Lining up payment with cost and performance encouraged professionals to provide the best quality care. One program of population-based subsidies for service fees (“fee subsidies”) in the Democratic Republic of Congo (ID 36) proved to increase the use of services in the short term and point to the need to study its sustainability, long-term effects and the possibility of removing or reducing fees for vulnerable users.

Technologies applied to PHC

Digital technologies stood out as means through which to increase effectiveness, especially with “Telehealth and Telemedicine” services. These are tools that provide reliable, updated and easily transferable information to clinical activities. Their value is for educational capacity and for expanding access and quality with reductions in cost. They also prevent unnecessary displacements and crowding at the reference centers, reducing hospitalization, strengthening integration between services and satisfaction for professionals and patients (ID 70; 40; 15; 50; 22; 89).

“Virtual consultations”, according to data from Canada (ID 83; 26; 28), were efficient in improving access to specialized care, besides being well accepted by professionals and patients. It can reduce waiting time, as well as the use of telephone to schedule appointments and to organize waiting lists (ID 03), referrals (ID 86), screening (ID 41), and electronic alerts to diminish patient no-show (ID 02).

Discussion

The main contributions to improve effectiveness in PHC were: sensitive conditions indicators, institutional assessment programs, focus on PHC as a structuring policy, quantitatively (number of doctors) and qualitatively appropriate workforces (multidisciplinary teams, nursing, community health agents), organizational measures to increase centers’ availability and the use of digital technologies.

However, it’s important to consider some aspects concerning the validity of this review. The choice of the keywords and the articles profile may have minimized relevant themes. That was the case of PHC coordination and integration with other levels of the system, in which access to specialized care and the waiting lists are one of the most important hurdles in PHC universal systems²⁰20 Conill EM, Fausto MCR, Giovanella L. Contribuic¸o~es da ana´lise comparada para um marco abrangente na avaliac¸a~o de sistemas orientados pela atenc¸a~o prima´ria na Ame´rica Latina. Rev Bras Saude Matern Infant 2010; 10(Supl. 1):15-27.. Although contemplated in the category ‘digital technologies’ and in the results from PMAQ and CFIHPS, there were few papers about this issue. There is also a lack of information on PHC reforms in countries such as Portugal²¹21 Biscaia AR, Heleno LCV. A Reforma dos Cuidados de Saúde Primários em Portugal: portuguesa, moderna e inovadora. Cien Saude Colet 2017; 22(3):701-712., especially concerning incentives to improve performance, which may have been published in reports or books.

The option to present the most frequent results in each category was also a relevant aspect, which may have prevented exploring less frequent ones, yet equally important themes. That is the case of “user’s satisfaction” in studies from Iran, Oman and Ecuador (ID 07; 13; 76), “accreditation” in Australia, the Netherlands and the United Kingdom (ID 27; 49; 08), models geared towards care approach centered on the person and on “the relationship” (ID 35; 25), and non-virtual technologies in “support to care” (ID 81). To minimize such limitations, Charts 1 and 2 enable access to the entire set of analyzed studies.

An expressive number of Brazilian studies showed indicators of emergency/hospital admissions due to PHC sensitive conditions, calling attention to the fact that other factors interfere in its effectiveness. This indicator is recommended for health care network evaluation, since it indicates possible problems concerning access and quality at all levels of care (ID 71; 74; 47). To better evaluate the PHC performance, a more comprehensive framework is needed to integrate questions at the macro level (policies) with the meso (management) and micro-social level (care)²⁰20 Conill EM, Fausto MCR, Giovanella L. Contribuic¸o~es da ana´lise comparada para um marco abrangente na avaliac¸a~o de sistemas orientados pela atenc¸a~o prima´ria na Ame´rica Latina. Rev Bras Saude Matern Infant 2010; 10(Supl. 1):15-27..

Besides these conceptual challenges, instruments and mechanisms which aim to apply PHC sensitive conditions must be operational and sustainable. They should consider data sub-registers and those from private services. Methodological and contextual differences also make comparisons more difficult. Many countries do not apply a wide concept for effectiveness as a desirable outcome for PHC universal systems, with effectiveness measures based on selective services, defined by guidelines and financial costs⁷7 Brandão JRM. A atenc¸a~o prima´ria a` sau´de no Canada´: realidade e desafios atuais. Cad Saude Publica 2019; 35(J):e00178217..

Payment for performance approaches have increased in recent decades along with reforms in PHC services²²22 Poli Neto P, Faoro NT, Prado Júnior JC, Pisco LAC. Remuneração variável na Atenção Primária à Saúde: relato das experiências de Curitiba e Rio de Janeiro, no Brasil, e de Lisboa, em Portugal. Cien Saude Colet 2016; 21(5):1377-1388., but their effects must be discussed further. Studies in Brazil (ID 73; 82; 59) and in the Netherlands (ID 68; 24; 31) suggest positive results. However, the experience in the United Kingdom with the Quality and Outcomes Framework proved not to be cost-effective (ID 29; 68) since payment rewards were not in line with health incomes, in this case focusing on mortality rather than PHC attributes. A recent study concerning the Brazilian PMAQ points out the capability to improve access and quality, even so indirect professionals remuneration depended on a complex evaluative model and certification process¹⁰10 Facchini L, Tomasi E, Thumé E. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021..

The present study confirms the polysemy of ‘resolvability’, concept embraced in Brazil, associated with the idea that most of the demands could be solved by PHC without referral to other services⁴4 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco/MS; 2002.^,²³23 Chioro A, Scaff A. Saúde e cidadania: a implantação do Sistema Único de Saúde. Santos: Faculdade de Cie^ncias Me´dicas de Santos; 1999.. This concept isn’t the same in English (effectiveness or responsiveness), nor in Spanish (modelo resolutivo or capacidad resolutiva). Effectiveness evaluate the level at which services reach the expected results in common practical conditions, or the relationship between its potential and real impact, which is closely related to results and classic PHC attributes (ID17)²⁴24 Donabedian A. The Seven Pillars of Quality. Arch Pathol Lab Med 1990; 114:1115-1118.^,²⁵25 Poças KC. Avaliação da Atenção Primária à Saúde no Distrito Federal [tese]. Brasília: Universidade de Brasília; 2017.. Responsiveness is the capacity to respond and the system fundamental objective of anticipating and adapting to existing and future needs for better results in health care. It focuses on individuals’ experiences and on how the health systems meet expectations, concerning: dignity, autonomy, confidentiality, immediate care, facilities quality, access to social support networks and service providers choice²⁶26 Mirzoev T, Kane S. What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework. BMJ Glob Health 2017; 2:e000486.. These concepts are close to the way ‘resolvability’ has been understood in Brazil, all of which related to the evaluation field. Although, a clearer differentiation is needed in order to facilitate an adequate use.

“Resolvability” according to Brazil’s common use corresponds to the act of establishing effective solutions for health problems, with beneficial results in individual or collective problems²⁷27 Rezende VA. A resolutividade na Atenção Básica: uma revisão de literatura [monografia]. Belo Horizonte: Universidade Federal de Minas Gerais; 2010.

28 Oliveira IPRM. Resolubilidade do cuidado oftalmolo´gico em centro de atendimento secunda´rio sob a o´tica dos pacientes diabe´ticos e na~o diabe´ticos [dissertac¸a~o]. Botucatu: Universidade Estadual Paulista Ju´lio de Mesquita Filho; 2017.^-²⁹29 Degani VC. A resolutividade dos problemas de saúde: opinião de usuários em uma Unidade Básica de Saúde [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2002.. Implies the possibility of identifying community needs, which will not necessarily appear as demands. This is where the challenge of this concept lies: identifying outcomes which may be expected in this level of care, taking into account the system’s conditioning factors, as well as the socioeconomic and cultural determinants that influence health in general.

Final considerations

The expressive number of Brazilian publications shows the important diffusion of PHC in this country over the last decade, as well as the concern with its performance. The scope reinforces already well-known aspects: a positive induction of institutional evaluation, organizational arrangements to improve institutional capacity and services availability, quantitatively and qualitatively appropriate workforces, PHC as a structuring policy and the use of digital resources. However payment for performance is still controversial. Complementary studies are warranted in order to overcome the thematic limitations or the bias of the present study.

The polysemy that surrounds the concept “resolvability” in Brazil proves the need for greater clarity in its application, identifying what is intended as effectiveness within PHC. Therefore, a logical model should be considered, with parameters which contemplate determinants and conditioning that influence PHC. We also suggest substituting the word “resolvability” as used in Brazil for ‘effectiveness to facilitate an international dialogue concerning outcomes in evaluation.

References

¹
Viacava F, Almeida C, Caetano R, Fausto M, Macinko J, Martins M, Noronha JC, Novaes HMD, Oliveira ES, Porto SM, Silva LMV, Szwarcwald CL. Uma metodologia de avaliac¸a~o do desempenho do sistema de sau´de brasileiro. Cien Saude Colet 2004; 9(3):711-724.
²
Tyrovolas S, Polychronopoulos E, Tountas Y, Panagiotakos D. The role of health care systems on populations' health status and longevity: A comprehensive analysis. Health Sci J 2010; 4(3):149-156.
³
Giovanella L, Mendonça MHM, Buss PM, Fleury S, Gadelha CAG, Galvão LAC, Santos RF. De Alma-Ata a Astana. Atenc¸a~o prima´ria a` sau´de e sistemas universais de sau´de: compromisso indissocia´vel e direito humano fundamental. Cad Saude Publica 2019; 35(3):e00012219.
⁴
Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco/MS; 2002.
⁵
Almeida PF, Fausto MCR, Giovanella L. Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Rev Panam Salud Publica 2011; 29(2):84-95.
⁶
Bitton A, Ratcliffe HL, Veillard JH, Kress DH, Barkley S, Kimball M, Secci F, Wong E, Basu L, Taylor C, Bayona J, Wang H, Lagomarsino G, Hirschhorn LR. Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries. J Gen Intern Med 2017; 32(5):566-571.
⁷
Brandão JRM. A atenc¸a~o prima´ria a` sau´de no Canada´: realidade e desafios atuais. Cad Saude Publica 2019; 35(J):e00178217.
⁸
Brasil. Portaria de Consolidação nº 2, de 28 de setembro de 2017. Política Nacional de Atenção Básica. Anexo XXII. Diário Oficial da União 2017; 28 set.
⁹
Conill EM. Análisis de la problemática de la integración de la APS en el contexto actual: causas que inciden en la fragmentación de servicios y sus efectos en la cohesión social. Intercambio III 2-1-2007. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca/Fiocruz; 2007.
¹⁰
Facchini L, Tomasi E, Thumé E. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021.
¹¹
Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020.
¹²
D´Aguiar JMM. O Programa Saúde da Família no Brasil. A resolutividade do PSF no município de Volta Redonda (RJ) [dissertação]. Rio de Janeiro: ENSP-Fiocruz; 2001.
¹³
Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidência na saúde e na enfermagem. Texto Context Enferm 2008; 17(4):758-764.
¹⁴
Page MJ, Mckenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71.
¹⁵
Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR. Gestão em saúde na atenção primária: o que é tratado na literatura. Texto Contexto Enferm 2019; 28:e20160426.
¹⁶
Silva FS, Catelli F. Os modelos na ciência: traços da evolução histórico-epistemológica. Rev Bras Ensino Fis 2019; 41:4.
¹⁷
Souza MF. Conceitos básicos em monitoramento e avaliação [aula]. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2013.
¹⁸
Pereira IB. Dicionário da educação profissional em saúde. 2ª ed. Rio de Janeiro: EPSJV; 2008.
¹⁹
Freitas MA. Arranjos organizativos da atenc¸a~o primária nas regio~es de sau´de de um Departamento Regional de Sau´de [dissertação]. Ribeira~o Preto: Universidade de Sa~o Paulo; 2017.
²⁰
Conill EM, Fausto MCR, Giovanella L. Contribuic¸o~es da ana´lise comparada para um marco abrangente na avaliac¸a~o de sistemas orientados pela atenc¸a~o prima´ria na Ame´rica Latina. Rev Bras Saude Matern Infant 2010; 10(Supl. 1):15-27.
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Rehem TCMSB, Ciosak SI, Egry EY. Internações por condições sensíveis à atenção primária no hospital geral de uma microrregião de saúde do município de São Paulo, Brasil. Texto Contexto Enferm 2012; 21(3):535-542.
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Oliveira ESBE, Oliveira VB, Caldeira AP. Internações por condições sensíveis à atenção primária em Minas Gerais, entre 1999 e 2007. Rev Baiana de Saude Publica 2017; 41(1):144-157.
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Funding
The production of this article received financial support from the Pós-Graduação of Universidade de Brasília through Public Notice DPG number 0001/2022.

Publication Dates

Publication in this collection
04 Sept 2023
Date of issue
Sept 2023

History

Received
25 Sept 2022
Accepted
11 Jan 2023
Published
13 Jan 2023

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

ID	Study	Place of origin
1	Báscolo, 2010³⁰30 Báscolo E. Gobernanza de las organizaciones de salud basados en Atención Primaria de Salud. Rev Salud Publica 2010; 12(1):8-27.	Argentina
2	Perron et al., 2010³¹31 Perron NJ, Dao MD, Kossovsky MP, Miserez V, Chuard C, Calmy A, Gaspoz JM. Reduction of missed appointments at an urban primary care clinic: a randomised controlled study. BMC Fam Pract 2010; 11:79.	Switzerland
3	Vieira-da-Silva et al., 2010³²32 Vieira-da-Silva LM, Chaves SC, Esperidião MA, Lopes-Martinho RM. Accessibility to primary healthcare in the capital city of a northeastern state of Brazil: an evaluation of the results of a programme. J Epidemiol Community Health 2010; 64(12):1100-1105.	Brazil
4	Miller et al., 2010³³33 Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaén CR. Primary care practice development: a relationship-centered approach. Ann Fam Med 2010; 8(Supl. 1):S68-S79.	USA
5	Yavich et al., 2010³⁴34 Yavich N, Báscolo EP, Haggerty J. Construyendo un marco de evaluación de la atención primaria de la salud para Latinoamérica. Salud Publica Mex 2010; 52(1):39-45.	Argentina
6	Nedel et al., 2011³⁵35 Nedel FB, Facchini LA, Bastos JL, Martín-Mateo M. Conceptual and methodological aspects in the study of hospitalizations for ambulatory care sensitive conditions. Cien Saude Colet 2011; 16(Supl. 1):1145-1154.	Brazil
7	Sohrabi and Albalushi, 2011³⁶36 Sohrabi MR, Albalushi RM. Clients' satisfaction with primary health care in Tehran: A cross-sectional study on Iranian Health Centers. J Res Med Sci 2011; 16(6):756-762.	Iran
8	Wilson, 2011³⁷37 Wilson T. Improving primary health care delivery: still waiting for the magic bullet. CMAJ 2011; 183(18):E1280-E1281.	United Kingdom
9	Szecsenyi et al., 2011³⁸38 Szecsenyi J, Campbell S, Broge B, Laux G, Willms S, Wensing M, Goetz K. Effectiveness of a quality-improvement program in improving management of primary care practices. CMAJ 2011; 183(18):E1326-E1333.	Germany
10	Rehem et al., 2012³⁹39 Rehem TCMSB, Ciosak SI, Egry EY. Internações por condições sensíveis à atenção primária no hospital geral de uma microrregião de saúde do município de São Paulo, Brasil. Texto Contexto Enferm 2012; 21(3):535-542.	Brazil
11	Baratieri et al., 2012⁴⁰40 Baratieri T, Mandu ENT, Marcon SS. Longitudinalidade no trabalho do enfermeiro: relatos da experiência profissional. Rev Esc Enferm USP 2012; 46(5):1260-1267.	Brazil
12	Grills et al., 2012⁴¹41 Grills NJ, Robinson P, Phillip M. Networking between community health programs: a case study outlining the effectiveness, barriers and enablers. BMC Health Serv Res 2012; 12:206.	India
13	Albalushi et al., 2012⁴²42 Albalushi RM, Sohrabi MR, Kolahi AA. Clients' satisfaction with primary health care in muscat. Int J Prev Med 2012; 3(10):713-717.	Oman
14	Ortiz and Wan, 2012⁴³43 Ortiz J, Wan TH. Performance of rural health clinics: an examination of efficiency and Medicare beneficiary outcomes. Rural Remote Health 2012; 12:1925.	USA
15	Alkmim et al., 2012⁴⁴44 Alkmim MB, Figueira RM, Marcolino MS, Cardoso CS, Pena de Abreu M, Cunha LR, et al. Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil. Bull World Health Organ 2012; 90(5):373-378.	Brazil
16	Oliveira et al., 2017⁴⁵45 Oliveira ESBE, Oliveira VB, Caldeira AP. Internações por condições sensíveis à atenção primária em Minas Gerais, entre 1999 e 2007. Rev Baiana de Saude Publica 2017; 41(1):144-157.	Brazil
17	Viacava et al., 2012⁴⁶46 Viacava F, Ugá MAD, Porto S, Laguardia J, Moreira RS. Avaliação de Desempenho de Sistemas de Saúde: um modelo de análise. Cien Saude Colet 2012; 17(4):921-934.	Brazil
18	Greaves et al., 2012⁴⁷47 Greaves F, Millett C, Pape UJ, Soljak M, Majeed A. Association between primary care organisation population size and quality of commissioning in England: an observational study. Br J Gen Pract 2012; 62(594):e46-e54.	England
19	Mold et al., 2012⁴⁸48 Mold JW, Lawler F, Schauf KJ, Aspy CB. Does patient assessment of the quality of the primary care they receive predict subsequent outcomes?: An Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med 2012; 25(4):e1-e12.	USA
20	Lima et al., 2012⁴⁹49 Lima RN, Medeiros Junior ME, Martins JS, Santos EP, Bourget MMM. Desempenho de indicadores nos municípios com alta cobertura da Estratégia Saúde da Família no Estado de São Paulo. Rev Bras Med Fam Comunidade 2012; 7(24):164-170.	Brazil
21	Campo, 2012⁵⁰50 Campo CB. Modelo de salud familiar en Chile y mayor resolutividad de la atención primaria de salud: ¿contradictorios o complementarios? Medwave 2012; 12(11):e5571.	Chile
22	Sanabria and Orta, 2012⁵¹51 Sanabria T, Orta M. The MANIAPURE Program-Lessons Learned from a Rural Experience: Two Decades Delivering Primary Healthcare Through Telemedicine. Telemed J E Health 2012; 18:544-548.	Venezuela
23	Dookie and Singh, 2012⁵²52 Dookie S, Singh S. Primary health services at district level in South Africa: a critique of the primary health care approach. BMC Fam Pract 2012; 13:67.	South Africa
24	Kirschner et al., 2012⁵³53 Kirschner K, Braspenning J, Jacobs JE, Grol R. Design choices made by target users for a pay-for-performance program in primary care: an action research approach. BMC Fam Pract 2012; 13:25.	The Netherlands
25	Lavoie et al., 2013⁵⁴54 Lavoie JG, Wong ST, Chongo M, Browne AJ, MacLeod MLP, Ulrich C. Group medical visits can deliver on patient-centred care objectives: results from a qualitative study. BMC Health Serv Res 2013; 13:155.	Canada
26	Liddy et al., 2013⁵⁵55 Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med 2013; 7(1):e1-e8.	Canada
27	Hinchcliff et al., 2013⁵⁶56 Hinchcliff R, Greenfield D, Westbrook JI, Pawsey M, Mumford V, Braithwaite J. Stakeholder perspectives on implementing accreditation programs: a qualitative study of enabling factors. BMC Health Serv Res 2013; 13:437.	Australia
28	Keely et al., 2013⁵⁷57 Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemed J E Health 2013; 19(10):733-738.	Canada
29	Ashworth et al., 2013⁵⁸58 Ashworth M, Schofield P, Doran T, Cookson R, Sutton M, Seed PT, Howe A, Fleetcroft R. The Public Health Impact score: a new measure of public health effectiveness for general practices in England. Br J Gen Pract 2013; 63(609):e291-e299.	England
30	Heard et al., 2013⁵⁹59 Heard A, Nath DK, Loevinsohn B. Contracting urban primary healthcare services in Bangladesh - effect on use, efficiency, equity and quality of care. Trop Med Int Health 2013; 18(7):861-870.	Bangladesh
31	Kirschner et al., 2013⁶⁰60 Kirschner K, Braspenning J, Akkermans RP, Jacobs JE, Grol R. Assessment of a pay-for-performance program in primary care designed by target users. Fam Pract 2013; 30(2):161-171.	The Netherlands
32	Chomatas et al., 2013⁶¹61 Chomatas E, Vigo A, Marty I, Hauser L, Harzheim E. Avaliação da presença e extensão dos atributos da atenção primária em Curitiba. Rev Bras Med Fam Comunidade 2013; 8(29):294-303.	Brazil
33	Zhao et al., 2013⁶²62 Zhao Y, Wright J, Guthridge S, Lawton P. The relationship between number of primary health care visits and hospitalisations: evidence from linked clinic and hospital data for remote Indigenous Australians. BMC Health Serv Res 2013; 13:466.	Australia
34	Violán et al., 2013⁶³63 Violán C, Plana-Ripoll O, Foguet-Boreu Q, Bolíbar B, Aguado A, Navarro-Artieda R, Velasco-Velasco S, Sicras-Mainar A. Relationship between efficiency and clinical effectiveness indicators in an adjusted model of resource consumption: a cross-sectional study. BMC Health Serv Res 2013; 13:421.	Spain
35	Porter et al., 2013⁶⁴64 Porter ME, Pabo EA, Lee TH. Redesigning Primary Care: A Strategic Vision to Improve Value By Organizing Around Patients' Needs. Health Affairs 2013; 32(3):516-525.	USA
36	Maini et al., 2014⁶⁵65 Maini R, Van Den Bergh R, Van Griensven J, Tayler-Smith K, Ousley J, Carter D, Mhatre S, Ho L, Zachariah R. Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study. BMC Health Serv Res 2014; 14:504.	D. Republic of Congo
37	Costa et al., 2014⁶⁶66 Costa JP, Jorge MSB, Vasconcelos MGF, De Paula ML, Bezerra IC. Resolubilidade do cuidado na atenção primária: articulação multiprofissional e rede de serviços. Saude Debate 2014; 38(103):733-743.	Brazil
38	Roots and Macdonald, 2014⁶⁷67 Roots A, Macdonald M. Outcomes associated with nurse practitioners in collaborative practice with general practitioners in rural settings in Canada: a mixed methods study. Hum Resour Health 2014; 12:69.	Canada
39	Rao and Pilot, 2014⁶⁸68 Rao M, Pilot E. The missing link - the role of primary care in global health. Glob Health Action 2014; 7:23693.	United Kingdom and The Netherlands
40	Piropo and Amaral, 2015⁶⁹69 Piropo TGN, Amaral HOS. Telessaúde, contextos e implicações no cenário baiano. Saude Debate 2015; 39(104):279-287.	Brazil
41	Campbell et al., 2015⁷⁰70 Campbell JL, Fletcher E, Britten N, Green C, Holt T, Lattimer V, Richards DA, Richards SH, Salisbury C, Taylor RS, Calitri R, Bowyer V, Chaplin K, Kandiyali R, Murdoch J, Price L, Roscoe J, Varley A, Warren FC. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess 2015; 19(13):1-212, vii-viii.	England
42	Castro et al., 2015⁷¹71 Castro ALB, Andrade CLT, Machado CV, Lima LD. Condições socioeconômicas, oferta de médicos e internações por condições sensíveis à atenção primária em grandes municípios do Brasil. Cad Saude Publica 2015; 31(11):2353-2366.	Brazil
43	Goetz et al., 2015⁷²72 Goetz K, Hess S, Jossen M, Huber F, Rosemann T, Brodowski M, Künzi B, Szecsenyi J. Does a quality management system improve quality in primary care practices in Switzerland? A longitudinal study. BMJ Open 2015; 5(4):e007443.	Switzerland
44	Farias et al., 2015⁷³73 Farias DC, Celino SDM, Peixoto JBS, Barbosa ML, Costa GMC. Acolhimento e Resolubilidade das Urgências na Estratégia Saúde da Família. Rev Bras Educ Med 2015; 39(1):79-87.	Brazil
45	Ford et al., 2015⁷⁴74 Ford JA, Jones AP, Wong G, Steel N. Weekend opening in primary care: analysis of the General Practice Patient Survey. Br J Gen Pract 2015; 65(641):e792-e798.	England
46	Mobula et al., 2015⁷⁵75 Mobula LM, Okoye MT, Boulware LE, Carson KA, Marsteller JA, Cooper LA. Cultural Competence and Perceptions of Community Health Workers' Effectiveness for Reducing Health Care Disparities. J Prim Care Community Health 2015; 6(1):10-15.	USA
47	Fung et al., 2015⁷⁶76 Fung CS, Wong CK, Fong DY, Lee A, Lam CLK. Having a family doctor was associated with lower utilization of hospital-based health services. BMC Health Serv Res 2015; 15:42.	China
48	Lemak et al., 2015⁷⁷77 Lemak CH, Nahra TA, Cohen GR, Erb ND, Paustian ML, Share D, Hirth RA. Michigan's Fee-For-Value Physician Incentive Program Reduces Spending and Improves Quality in Primary Care. Health Aff 2015; 34(4):645-652.	USA
49	Nouwens et al., 2015⁷⁸78 Nouwens E, Van Lieshout J, Wensing M. Determinants of impact of a practice accreditation program in primary care: a qualitative study. BMC Fam Pract 2015; 16:78.	The Netherlands
50	Markwick et al., 2015⁷⁹79 Markwick L, Mcconnochie K, Wood N. Expanding Telemedicine to Include Primary Care for the Urban Adult. J Health Care Poor Underserved 2015; 26(3):771-776.	USA
51	Brugués et al., 2016⁸⁰80 Brugués A, Peris Grao A, Pavón Rodríguez F, Mateo Viladomat E, Gascón Ferret J, Flores Mateo G. Evaluación de la gestión enfermera de la demanda en atención primaria. Aten Primaria 2016; 48(3):159-165.	Spain
52	Whittaker et al., 2016⁸¹81 Whittaker W, Anselmi L, Kristensen SR, Lau YS, Bailey S, Bower P, Checkland K, Elvey R, Rothwell K, Stokes J, Hodgson D. Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis. PLoS Med 2016; 13(9):e1002113.	England
53	Leite et al., 2016⁸²82 Leite RS, Santos APM, Lima CA, Ribeiro CDAL, Brito MFSF. Estratégia Saúde da Família versus centro de saúde: modalidades de serviços na percepção do usuário. Cad Saude Colet 2016; 24(3):323-329.	Brazil
54	Penm et al., 2017⁸³83 Penm J, Mackinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the Gap: Factors Associated With Primary Care Coordination of Adults in 11 Countries. Ann Fam Med 2017; 15(2):113-119.	Australia, Canada, France, Germany, The Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom and USA
55	Hone et al., 2017⁸⁴84 Hone T, Rasella D, Barreto M, Atun R, Majeed A, Millett C. Large reductions in amenable mortality associated with Brazil's Primary Care expansion and strong health governance. Health Aff (Millwood) 2017; 36(1):149-158.	Brazil
56	Ebert et al., 2017⁸⁵85 Ebert ST, Pittet V, Cornuz J, Senn N. Development of a monitoring instrument to assess the performance of the Swiss primary care system. BMC Health Serv Res 2017; 17(1):789.	Switzerland
57	Murante et al., 2017⁸⁶86 Murante AM, Seghieri C, Vainieri M, Schäfer WLA. Patient-perceived responsiveness of primary care systems across Europe and the relationship with the health expenditure and remuneration systems of primary care doctors. Soc Sci Med 2017; 186:139-147.	Europe
58	Zarlotti et al., 2017⁸⁷87 Zarlotti C, Scudese E, Sena GW, Tonini T, Lopes T, Pestana C. Internações por condições sensíveis à atenção primária após a implantação da estratégia saúde da família no município de Petrópolis/RJ. R Pesq Cuid Fundam Online 2017; 9(3):811-817.	Brazil
59	Miclos et al., 2017⁸⁸88 Miclos PV, Calvo MCM, Colussi CF. Evaluation of the performance of actions and outcomes in primary health care. Rev Saude Publica 2017; 51:86.	Brazil
60	Mendonça et al., 2017⁸⁹89 Mendonça CS, Leotti VB, Dias-da-Costa JS, Harzheim E. Hospitalizations for primary care sensitive conditions: association with socioeconomic status and quality of family health teams in Belo Horizonte, Brazil. Health Policy and Plan 2017; 32(10):1368-1374.	Brazil
61	Molina et al., 2017⁹⁰90 Molina J, Tasca R, Suárez J, Kemper ES. More Doctors Programme and the strengthening of Primary Health Care in Brazil: Reflections from the monitoring and evaluation of the More Doctors Cooperation Project. Qual Prim Care 2017; 25(2):50-54.	Brazil
62	Chang et al., 2017⁹¹91 Chang CH, O'Malley AJ, Goodman DC. Association between Temporal Changes in Primary Care Workforce and Patient Outcomes. Health Serv Res 2017; 52(2):634-655.	USA
63	Wagner et al., 2017⁹²92 Wagner EH, Flinter M, Hsu C, Cromp DA, Austin BT, Etz R, Crabtree BF, Ladden MD. Effective team-based primary care: observations from innovative practices. BMC Fam Pract 2017; 18:13.	USA
64	Segalini et al., 2017⁹³93 Segalini AM, Weisbrot M, Vietto V, Rezzónico M, Peña FV, Kopitowski K, Terrasa SA. Valoracio´n de la atencio´n primaria de la salud en el Centro de Medicina Familiar y Comunitaria San Pantaleo´n desde la perspectiva de los profesionales de la salud: estudio de corte transversal. Rev Hosp Ital B Aires 2017; 37(1):4-9.	Argentina
65	Wan et al., 2018⁹⁴94 Wan S, Teichmanb PG, Latifa D, Boydc J, Gupta R. Healthcare provider perceptions of the role of interprofessional care in access to and outcomes of primary care in an underserved area. J Interprof Care 2018; 32(2):220-223.	USA
66	Zhou et al., 2018⁹⁵95 Zhou Y, Bai G, Lou L. Development of a hexagonal, mesh-based distribution method for community health centres. Geospat Health 2018;13:2.	China
67	Mukiapini et al., 2018⁹⁶96 Mukiapini S, Bresick G, Sayed A-R, Le Grange C. Baseline measures of primary health care team functioning and overall primary health care performance at Du Noon Community Health Centre. Afr J Prm Health Care Fam Med 2018; 10(1):a1458.	South Africa
68	Pandya et al., 2018⁹⁷97 Pandya A, Doran T, Zhu J, Walker S, Arntson E, Ryan AM. Modelling the cost-effectiveness of pay-for-performance in primary care in the UK. BMC Med 2018; 16:135.	United Kingdom
69	Lin et al., 2018⁹⁸98 Lin Y, Wan N, Sheets S, Gong X, Davies A. A multi-modal relative spatial access assessment approach to measure spatial accessibility to primary care providers. Int J Health Geogr 2018; 17:33.	USA
70	Tintorer et al., 2018⁹⁹99 Tintorer DL, Domínguez JMM, Pujol-Rivera E, Beneyto SF, Tuduri XM, Saigí-Rubió F. Keys to success of a community of clinical practice in primary care: a qualitative evaluation of the ECOPIH project. BMC Fam Pract 2018; 19(1):56.	Spain
71	Arantes et al., 2018¹⁰⁰100 Arantes LJ, Shimizu HE,Mercha´n-Hamann E. Ambulatory care sensitive hospitalizations after implementation of the master plan in Minas Gerais. Rev Saude Publica 2018; 52:78.	Brazil
72	Balasubramanian et al., 2018¹⁰¹101 Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL, Stange KC, Solberg LI. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices. Ann Fam Med 2018; 16(Supl. 1):S35-S43.	USA
73	Lima et al., 2018¹⁰²102 Lima JG, Giovanella L, Fausto MCR, Bousquat A, Silva EV. Atributos essenciais da Atenção Primária à Saúde: resultados nacionais do PMAQ-AB. Saude Debate 2018; 42(n. esp. 1):52-66.	Brazil
74	Santos et al., 2018¹⁰³103 Santos LPR, Castro ALB, Dutra CGP, Guimarães RM. Internações por condições sensíveis à atenção primária à saúde, 2008-2015: uma análise do impacto da expansão da ESF na cidade do Rio de Janeiro. Cad Saude Colet 2018; 26(2):178-183.	Brazil
75	Hayhoe et al., 2018¹⁰⁴104 Hayhoe B, Cowling TE, Pillutla V, Garg P, Majeed A, Harris M. Integrating a nationally scaled workforce of community health workers in primary care: a modelling study. J R Soc Med 2018; 111(12):453-461.	England
76	Fariño Cortez et al., 2018¹⁰⁵105 Fariño Cortez JE, Vera Lorenti FE, Cercado Mancero AG, Velasco Donoso AP, Millaico Noriega MJ, Saldarriaga Jiménez DG. Satisfacción de usuarios y calidad de atención en unidades primarias de Salud de Milagro. INSPILIP 2018; 2(2):2-25.	Spain
77	Lima-Toivanen and Pereira, 2018¹⁰⁶106 Lima-Toivanen M, Pereira RM. The contribution of eHealth in closing gaps in primary health care in selected countries of Latin America and the Caribbean. Rev Panam Salud Publica 2018; 42:188.	Argentina, Brazil, Costa Rica and Dominican Republic
78	Wensing et al., 2018¹⁰⁷107 Wensing M, Kolle PK, Szecsenyi J, Stock C, Laux G. Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study. Scand J Prim Health Care 2018; 36(2):109-114.	Germany
79	Cole, 2018¹⁰⁸108 Cole ES. Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes. J Am Board Fam Med 2018; 31(4):605-611.	USA
80	Abel et al., 2018¹⁰⁹109 Abel J, Kingston H, Scally A, Hartnoll J, Hannam G, Thomson-Moore A, Kellehear A. Reducing emergency hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities. Br J Gen Pract 2018; 68(676):e803-e810.	United Kingdom
81	Fairall et al., 2018¹¹⁰110 Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit. BMJ 2018; 363:k4451.	South Africa
82	Ferreira et al., 2018¹¹¹111 Ferreira LR, Silva Júnior JA, Arrigotti T, Neves VR, Silva RA. Influences of the program for access and quality improvement in work processes in primary care. Rev Esc Enferm USP 2018; 52:e03407.	Brazil
83	Nabelsi et al., 2019¹¹²112 Nabelsi V, Lévasque-Chouinard A, Liddy C, Pilon MD. Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study. JMIR Med Inform 2019; 7(3):e13354.	Canada
84	Navathe et al., 2019¹¹³113 Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Stollar M, Tom J, Gold M, Volpp KG. Association Between the Implementation of a Population-Based Primary Care Payment System and Achievement on Quality Measures in Hawaii. JAMA 2019; 322(1):57-68.	Hawaii
85	Lenzi et al., 2019¹¹⁴114 Lenzi H, Ben AJ, Stein AT. Development and validation of a patient no-show predictive model at a primary care setting in Southern Brazil. PLoS ONE 2019; 14(4):e0214869.	Brazil
86	Azogil-López et al., 2019¹¹⁵115 Azogil-López LM, Pérez-Lázaro JJ, Ávila-Pecci P, Medrano-Sánchez EM, Coronado-Vázquez MV. Efectividad de un nuevo modelo de derivación telefónica compartida entre atención primaria y atención hospitalaria. Aten Primaria 2019; 51(5):278-284.	Spain
87	Ballart and Galais, 2019¹¹⁶116 Ballart X, Galais C. ¿Gestión pública, privada o por el tercer sector? Diferencias en los resultados en atención primaria de Cataluña. Aten Primaria 2019; 51(10):610-616.	Spain
88	Sibbald et al., 2019¹¹⁷117 Sibbald SL, Selkirk K, Cherla A, Misra V. An Opportunity for Quality: The Need for Better Evaluation of Family Health Teams in Ontario. Healthc Q 2019; 21:4.	Canada
89	Harzheim et al., 2019¹¹⁸118 Harzheim E, Chueiri PS, Umpierre RN, Gonçalves MR, Siqueira ACS, D'avila OP, Molina Bastos CG, Katz N, Dal Moro RG, Telles LF, Schmitz CAA. Telessaúde como eixo organizacional dos sistemas universais de saúde do século XXI. Rev Bras Med Fam Comunidade 2019; 14(41):1881.	Brazil
90	Tasca et al., 2020¹¹⁹119 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim, E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e4.	Brazil

Thematic categories	Themes	Subthemes	Absolute number	Percentage
Strategies for PHC quality monitoring and services evaluation	General	PHC quality assessment (ID 88)	1	1.1%
	Indicators	Emergency/hospital admissions by PHC sensitive conditions (ID 71; ID 74; ID 10; ID 06; ID 42; ID80; ID 78; ID 16; ID 60; ID 58; ID 47; ID 33)	12	13.3%
	PHC Attributes	Primary Care Assessment Tool (ID 32; ID 67; ID 64); Care coordination (ID 54); Access (ID 69)	5	5.6%
	Institutional Assessment Programs	CPCQ (ID 72). SPAM (ID 56). European Practice Assessment (ID 43; ID 09). PMAQ-AB (ID 73; ID 82; ID 59). Estrategia de Evaluación Reformulada para Latinoamérica (ID 05). Pacto pela Atenção Básica/Pacto pela Saúde (ID 20). Public Health Impact (ID 29). PROADESS (ID 17)	11	12.2%
	e-Health	e-PHC Assessment Framework (ID 77)	1	1.1%
	User’s satisfaction	User’s satisfaction (ID 07; ID 13; ID 76; ID 19)	4	4.5%
Subtotal			34	37.8%
Models	General	PHC in Global Health (ID 39)	1	1.1%
	General	Governability (ID 01)	1	1.1%
	Payment	For populational basis (ID 84; ID 57)	2	2.3%
		For performance (ID 68; ID 24; ID 31)	3	3.3%
		Fee-for-service (ID 48; ID 79), fee subsidies (ID 36)	3	3.3%
	Accreditation	Accreditation (ID 27; ID 49; ID 08)	3	3.3%
	Models of Care	Care approach centered on: person (ID 35; ID 25); relationship (ID 04)	3	3.3%
	Models of Care	Patient no-show predictive model (ID 85)	1	1.1%
Subtotal category			17	18.9%
Organizational arrangements	Multidisciplinary teams	Team set-up/practices (ID 63; ID 65; ID 62; ID 51; ID 38; ID 11; ID 75)	7	7.8%
	Services organization	Extended hours (ID 52; ID 45), Team work (ID 46; ID 37), Distribution of teams/professionals (ID 66; ID 18; ID 23); urgencies (ID 44)	8	8.9%
	Structuring strategies	Family health (ID 90; ID 53; ID 55; ID 21), Rural Health Clinics (ID 14), More Doctors (ID 61), Adjusted Clinical Groups (ID 34)	7	7.8%
	Management	Non-governmental organizations (ID 30); Associative Basis Entities (ID 87); and Networking clusters (ID 12)	3	3.3%
Subtotal category			25	27.8%
Technologies applied to PHC	Digital	Telehealth and Telemedicine (ID 70; ID 40; ID 15; ID 50; ID 22; ID 89)	6	6.7%
		Virtual Appointments (ID 83; ID 26; ID 28)	3	3.3%
		Use of telephone for: scheduling appointments and waiting list (ID 03); reference/referral (ID 86); screening (ID 41); and electronic alert (ID 02)	4	4.5%
	Non-digital	Support to care: Practical Approach to Care Kit (ID 81)	1	1.1%
Subtotal category			14	15.5%
Total			90	100%

ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br

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Saúde Pública

Saúde Pública

What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020

Abstract

Introduction

Methodology

Results

Strategies for PHC quality monitoring and services evaluation

Organizational arrangements

Models

Technologies applied to PHC

Discussion

Final considerations

References

Funding

Publication Dates

History