Abstract

Primary Health Care (PHC) proved to be an important part of the prevention, control and treatment measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services as well. This article identifies the main arrangements made to provide PHC care in the context of the COVID-19 pandemic. An integrative literature review of articles found in PubMed, SciELO and LILACS databases was performed using the descriptors “Primary Health Care” and “COVID-19”. Findings were analyzed considering three questions: Information and Communication Technologies (ICT), Organizations of Work Processes and Non-COVID Chronic Diseases. The use of different forms of ICT to provide PHC is highlighted regarding patients with respiratory symptoms and chronic patients. Changes in team composition, service flows, physical spaces and working hours were also introduced. Although strategies aimed at monitoring chronic patients and at remote care may have helped minimize deterioration of their health, the decrease in the number of visits performed during this period could have resulted in an increased demand for PHC in post-pandemic years.

Key words:
COVID-19; Primary Health Care; Health Policy

Introduction

The COVID-19 pandemic has imposed new challenges on health managers worldwide and in Brazil, on the three government area in charge of managing the Brazilian Public Health System (SUS) to ensure immediate responses to the greatest health crisis of this century. The speed and high rate of transmission of the SARS-CoV-2 virus, as well as the occurrence of serious and fatal cases significantly impacted health networks, pointing to the risk of a collapse due to the development of the disease to Acute Severe Respiratory Syndrome. The resilience of health systems and services was put to the test, requiring plasticity, organizational capacity and the production of technological care arrangements capable of reconfiguring, in a short period of time, offers, flows and work processes at different care network points¹1 Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, Chua A, Verma M, Shrestha P, Singh S, Perez T, Tan SM, Bartos M, Mabuchi S, Bonk M, McNab C, Werner GK, Panjabi R, Nordström A, Legido-Quigley H. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med 2021; 27:964-980..

Primary Health Care (PHC) proved to be an important part of prevention, diagnosis, treatment and monitoring measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services to the population²2 Resende TC, Paschoalotto MAC, Peckham S, Passador CS, Passador JL. How did the UK government face the global COVID-19 pandemic? Rev Adm Publica 2021; 55(1):72-83.. Although much effort was made at the onset of the pandemic to increase the number of hospital beds and ventilatory support, most COVID-19 patients received PHC in the form of outpatient treatment³3 Kearon J, Risdon C. The Role of Primary Care in a Pandemic: Reflections During the COVID-19 Pandemic in Canada. J Prim Care Community Health 2020; 11:2150132720962871.

4 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(8):e00149720.^-55 Seixas CT, Merhy EE, Feuerwerker LCM, Santo TBDE, Slomp Junior H, Cruz KT. A crise como potência: os cuidados de proximidade e a epidemia pela Covid-19. Interface (Botucatu) 2021; 25:e200379..

Although every country configures PHC in different ways, it is one of the key components of every effective health system⁶6 Organização Pan-Americana de Saúde (OPAS). Renovação da Atenção Primária em Saúde nas Américas: documento de posicionamento da Organização Pan-Americana da Saúde. Brasília: OPAS/OMS; 2008. and a link of the care network that, due to its territorial base, allows establishing a closer contact to individuals, families and the community⁷7 World Health Organization (WHO). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR [Internet]. [cited 2023 jun 25]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/almaata-declaration-en.pdf?sfvrsn=7b3c2167_2.
https://cdn.who.int/media/docs/default-s... . National health systems (NHS) rely on PHC as a powerful device to organize and coordinate care, given its capillarity, information on users and suitability to find adequate solutions to the various health challenges faced by people in their processes of illness and care⁷7 World Health Organization (WHO). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR [Internet]. [cited 2023 jun 25]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/almaata-declaration-en.pdf?sfvrsn=7b3c2167_2.
https://cdn.who.int/media/docs/default-s... .

PHC assumes greater sanitary responsibility than other care network links, as its collective health surveillance, promotion and prevention actions exceed the individual dimension of care⁵5 Seixas CT, Merhy EE, Feuerwerker LCM, Santo TBDE, Slomp Junior H, Cruz KT. A crise como potência: os cuidados de proximidade e a epidemia pela Covid-19. Interface (Botucatu) 2021; 25:e200379.. Given this context, there is evidence that National Health Systems (NHS) strongly rooted in PHC respond more effectively to health emergencies⁸8 Giovanella L, Martufi V, Ruiz DC, Mendonça MHM, Bousquat A, Aquino R, Medina MG. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate 2021; 45(130):748-762.^,99 Redwood-Campbell L, Abrahams J. Primary Health care and Disasters-The Current State of the Literature: What We Know, Gaps and Next Steps. Prehosp Disaster Med 2011; 26(3):184-191.. The COVID-19 pandemic put to the test countries that were not able to develop coordinated territorial actions with other health network components⁵5 Seixas CT, Merhy EE, Feuerwerker LCM, Santo TBDE, Slomp Junior H, Cruz KT. A crise como potência: os cuidados de proximidade e a epidemia pela Covid-19. Interface (Botucatu) 2021; 25:e200379., which worsened access inequalities and difficulties that had existed before the pandemic.

In Brazil, PHC works in many different ways, due to the heterogeneity and particularities of Brazilian regions and municipalities¹⁰10 Cecilio LCO, Reis AAC. Apontamentos sobre os desafios (ainda) atuais da atenção básica à saúde. Cad Saude Publica 2018; 34(8):e00056917.. The COVID-19 pandemic broke out at a time when PHC was affected by government measures that jeopardized the doctrinal principles of the Brazilian Public Health System (SUS). Some examples include the impacts of Constitutional Amendment No. 95, which limited public spending; the change in National Primary Care Policy, which makes the composition of the Family Health Strategy teams more flexible; the implementation of the “Previne Brasil” program, which changed the traditional financing logic of PHC; and the suspension of the “Mais Médicos pelo Brasil” program, which further worsened the lack of health care services¹¹11 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.

12 Massuda A. Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Cien Saude Colet 2020; 25(4):1181-1188.

13 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(6):e00104120.

14 Lima HSC, Felipe JS, Silva JAA, Temporão JG, Padilha ARS, Reis AAC. SUS, saúde e democracia: desafios para o Brasil Manifesto de seis ex-ministros da saúde a propósito da 16a Conferência Nacional De Saúde. Cien Saude Colet 2019; 24(10):3713-3716.^-1515 Chioro A, Gomes Temporão J, Massuda A, Costa H, Castro MC, Lima NT. From Bolsonaro to Lula: The opportunity to rebuild universal healthcare in Brazil in the government transition. Int J Health Plann Manage 2023; 38(3):569-578..

It is crucial to know what responses and innovations were developed to address the COVID-19 pandemic to understand responsiveness and organization of Health Systems¹⁶16 Merhy EE, Bertussi DC, Santos MLM, Rosa NSF, Slomp Junior H, Seixas CT. Pandemia, Sistema Único de Saúde (SUS) e Saúde Coletiva: com-posições e aberturas para mundos outros. Interface (Botucatu) 2022; 26:e210491., as there is evidence of a certain perspective of ambivalence of actions developed by PHC, such as presence-absence, plasticity-rigidity, or even experimentation-repetition during the COVID-19 pandemic. In this sense, this article aimed to identify the main arrangements that were developed to offer PHC care in the context of the COVID-19 pandemic.

Method

The present integrative literature review is part of a main research project funded by Fapesp/PPSUS which aims to analyze the productions, inventions and challenges in care management implemented by health care networks in two Health Regions of the State of São Paulo to address the COVID-19 pandemic, with an emphasis on PHC.

This integrative review was performed in six steps that were adapted from the methodology proposed by Mendes et al.¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764. and the presentation of results follows the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)¹⁸18 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, Mayi-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..

The present review answers the following guiding question: “What kind of innovations were introduced in Primary Health Care arrangements during the COVID-19 pandemic?” To this end, scientific publications from three different databases were surveyed from the beginning of the pandemic to March 2022: Lilacs, SciELO and PubMed. MESH and DeCS descriptors “Primary Health Care” and “COVID-19” were used and combined with the Boolean operator “AND”. Duplicate records were eliminated and studies were evaluated by their titles and abstracts using the Rayyan electronic platform¹⁹19 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5(1):210-220. to make sure they met all inclusion and exclusion criteria. Selected articles were read in full to check their eligibility.

All publications found in the databases that answered the research question were included, regardless the language or place where the study was carried out. Articles that did not answer the guiding question were excluded, just as editorials, letters to the editor, comments, essays, opinion articles, reviews and articles that investigated the use of medication or other forms of treatment. All bibliographic references of selected articles were reviewed to find additional articles that could be included in the review.

Articles included in the review were analyzed regarding their year of publication, language, data collection period, place of execution, methodology and main results that would show innovative care arrangements in PHC.

Results and discussion

By applying the criteria described above, the survey found 2,185 articles, 25 of which were duplicates and thus excluded. After reading their titles and abstracts, 127 articles were selected for full reading, 67 of which were included in the review and fully analyzed (Figure 1). Chart 1 presents the main findings of the studies analyzed by the present review.

Most of the reviewed articles were published in English, i.e., 58 studies, followed by 7 articles published in Portuguese. Research took mostly place in the United States (23 studies), followed by Brazil and the U.K. (8 studies each) and Canada (7 studies).

Seventeen articles were published in 2020 and another 44 in 2021. Regarding the time of data collection or period studied, 49 studies used data from the first term of 2020 and only three studies used data from 2021.

Results highlight three main topics that are analyzed and discussed below: Information and Communication Technologies (ICT), Work Process Organizations and Non-COVID Chronic Diseases.

Information and Communication Technologies

Use of ICT is mentioned in almost all articles analyzed by the review, varying in terms of form and intensity of use. Use of ICT is justified as a strategy to ensure physical distancing due to the COVID-19 virus’ high potential for its spread in closed spaces, such as health care clinics²⁰20 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(2):e2020166..

The types of ICT used varied significantly from place to place where research took place. Most of them included phones, text or video messaging applications²¹21 Silva WRS, Duarte PO, Felipe DA, Sousa FOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19. Trab Educ Saude 2021; 19:e00330161.

22 Fernandez M, Lotta G, Corrêa M. Desafios para a Atenção Primária à Saúde no Brasil: uma análise do trabalho das agentes comunitárias de saúde durante a pandemia de Covid-19. Trab Educ Saude 2021; 19:e210142.^-2323 Ghafri T Al, Al Ajmi F, Anwar H, Balushi LA, Balushi ZA, Fahdi FA, Lawati AA, Hashmi SA, Ghamari AA. Harthi MA, Kurup P, Lamki MA, Manji AA, Aharji AA, Harthi SA, Gibson E. The Experiences and Perceptions of Health-Care Workers During the COVID-19 Pandemic in Muscat, Oman: A Qualitative Study. J Prim Care Community Health 2020; 11:2150132720967514., SMS messages²⁴24 Mohammed HT, Hyseni L, Bui V, Gerritsen B, Fuller K, Sung J, Alarakhia M. Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use. PLoS One 2021; 16(6):e0253665., telemedicine platforms and social networks²⁵25 Ashcroft R, Donnelly C, Dancey M, Gill S, Lam S, Kourgiantakis T, Adamson K, Verrilli D, Dolovich L, Kirvan A, Mehta K, Sur D, Brown JB. Primary care teams' experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study. BMC Fam Pract 2021; 22(1):143-155..

These technologies were used for care and monitoring of respiratory symptomatic patients and confirmed cases of COVID-19. Text messaging or SMS applications were used to schedule appointments, perform triage and monitor patients with COVID-19 or other chronic diseases. One study states the use of automation mechanisms by a messaging application, which allows monitoring COVID-19 patients by automatically providing users with guidelines that meet their description of health issues²⁶26 Lim HM, Abdullah A, Ng CJ, Teo CH, Valliyappan IG, HAdi HA, Ng WL, Azhar AMN, Chiew TK, Liew CS, Chan CS. Utility and usability of an automated COVID-19 symptom monitoring system (CoSMoS) in primary care during COVID-19 pandemic: A qualitative feasibility study. Int J Med Inform 2021; 155:104567..

ICT has also been used extensively to support chronically ill patients, including telemedicine consultations and phone monitoring of patients²³23 Ghafri T Al, Al Ajmi F, Anwar H, Balushi LA, Balushi ZA, Fahdi FA, Lawati AA, Hashmi SA, Ghamari AA. Harthi MA, Kurup P, Lamki MA, Manji AA, Aharji AA, Harthi SA, Gibson E. The Experiences and Perceptions of Health-Care Workers During the COVID-19 Pandemic in Muscat, Oman: A Qualitative Study. J Prim Care Community Health 2020; 11:2150132720967514.^,2727 Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marciniowicz L, Reinhardt K, Skoglund I, Sundvall P, Vellinga A, Verheij TJM, Goossens H, Butler CC, Velden A, Snthierens S, Tonkin-Crine S. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract 2021; 71(709):e634-e642.. Some health care clinics developed systems that issued daily reports of people with chronic conditions at higher risk who required closer monitoring by physicians²⁸28 Blazey-Martin D, Barnhart E, Gillis J, Vazquez GA. Primary Care Population Management for COVID-19 Patients. J Gen Intern Med 2020; 35(10):3077-3080.. Contact, active search and monitoring of these people by phone calls have also been reported²⁹29 Alboksmaty A, Kumar S, Parekh R, Aylin P. Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK - Qualitative assessment. PLoS One 2021; 16(3):e0248387.

30 Bhatti S, Commisso E, Rayner J. A Rapid Primary Healthcare Response to COVID-19: An Equity-Based and Systems- Thinking Approach to Care Ensuring that No One Is Left Behind. Healthc Q 2020; 23(3):29-33.

31 Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, Olmen J. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract 2020; 21(1):255-261.^-3232 Wilson G, Windner Z, Dowell A, Toop L, Savage R, Hudson B. Navigating the health system during COVID-19: primary care perspectives on delayed patient care. N Z Med J 2021; 134(1546):17-27..

Not only doctors made use of these technologies. Several members of multidisciplinary teams applied ICT to their professional activities, such as the practice of physical activities supervised by physical educators²¹21 Silva WRS, Duarte PO, Felipe DA, Sousa FOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19. Trab Educ Saude 2021; 19:e00330161., consultations with occupational therapists³³33 Sclarsky H, Kumar P. Community-Based Primary Care Management for an Older Adult With COVID-19: A Case Report. Am J Occup Ther 2021; 75:e75112110030., nurses³⁴34 James S, Ashley C, Williams A, Desborough J, Mcinnes S, Calma K, Mursa R, Stephen C, Halcomb EJ. Experiences of Australian primary healthcare nurses in using telehealth during COVID-19: a qualitative study. BMJ Open 2021; 11(8):e049095. and pharmacists³⁵35 Koster ES, Philbert D, Bouvy ML. Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies. Res Soc Adm Pharm 2021; 17(1):2002-2004..

In a short period of time, health professionals had to adapt their practice and start providing care services remotely, despite uncertainties about regulations and whether remote services should be paid or free³⁶36 DeVoe JE, Bazemore A. Primary Care in the COVID-19 Pandemic: Essential, and Inspiring. J Am Board Fam Med 2021; 34(Supl.):S1-S6.. According to a Canadian study, before the COVID-19 pandemic only 6.5% of physicians offered telemedicine consultations, a figure that jumped to 66.4% during the pandemic. Most of these professionals intended to keep practicing telemedicine after the pandemic as well²⁴24 Mohammed HT, Hyseni L, Bui V, Gerritsen B, Fuller K, Sung J, Alarakhia M. Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use. PLoS One 2021; 16(6):e0253665..

In Brazil, use of telemedicine has always been a matter of controversy among medical entities and to such an extent that the Federal Council of Medicine (CFM) revoked the ordinance issued in 2018 that authorized telemedicine approximately two months after its publication. The alleged reason was a “request from numerous medical entities that ask for more time to analyze the document”³⁷37 Conselho Federal de Medicina (CFM). Resolução no 2.227/2018. Define e disciplina a telemedicina como forma de prestação de serviços médicos mediados por tecnologias. Diário Oficial da União 2019; 6 fev.^,3838 Conselho Federal de Medicina (CFM). Resolução no 2.228/2019. Revoga a Resolução CFM nº 2.227, publicada no D.O.U. de 6 de fevereiro de 2019 , Seção I, p. 58, a qual define e disciplina a telemedicina como forma de prestação de serviços médicos mediados por tecnologias, e restabelece expressamente a vigência da Resolução CFM nº 1.643/2002, publicada no D.O.U. de 26 de agosto de 2002, Seção I, p. 205. Diário Oficial da União 2019; 6 mar.. Despite that fact, at the beginning of the pandemic, the CFM sent the Ministry of Health (MS) a letter declaring that it recognized the possibility of exceptionally using telemedicine during the COVID-19 pandemic³⁹39 Conselho Federal de Medicina (CFM). Ofício no 1.756, de 19 de março de 2020 - COJUR [Internet]. [acessado 2023 fev 18]. Disponível em: https://portal.cfm.org.br/images/PDF/2020_oficio_telemedicina.pdf.
https://portal.cfm.org.br/images/PDF/202... . Based on this official letter from CFM, the MS issued Ordinance No. 467/2020 regulating the use of telemedicine as one of the measures to address the pandemic⁴⁰40 Brasil. Ministério da Saúde (MS). Portaria no 467, de 20 de março de 2020. Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3º da Lei nº 13.979, de 6 de fevereiro de 2020, decorrente da epidemia de COVID-19. Diário Oficial da União 2020; 23 mar.. After that, the matter was regulated through the enactment of Law No. 13,989/2020⁴¹41 Brasil. Governo Federal. Lei no 13.989, de 15 de abril de 2020. Dispõe sobre o uso da telemedicina durante a crise causada pelo coronavírus (SARS-CoV-2). Diário Oficial da União; 2020..

The significant increase in the use of telemedicine during the pandemic was mentioned as one of the justifications for the publication of CFM Resolution No. 2,314/2022, which regulates the matter after the COVID-19 pandemic⁴²42 Conselho Federal de Medicina (CFM). Resolução no 2.314/2022. Define e regulamenta a telemedicina, como forma de serviços médicos mediados por tecnologias de comunicação. Diário Oficial da União 2022; 5 maio.. Establishing regulatory standards for the practice and payment of treatment by telemedicine associated with comparable care quality and user satisfaction are pointed out as important factors to keep up its use after the pandemic⁴³43 Byrne MD. Telehealth and the COVID-19 Pandemic. J PeriAnesthesia Nurs 2020; 35(5):548-551..

Despite uncertainties about the regulation regarding use of ICT, it is clear that its use often occurred spontaneously and autonomously, like a strategy created in an act, on initiative of professionals who were looking for ways to ensure care services without exposing people to the risk of contamination by the COVID-19 virus. The lack of official support for its use, paired with a lack of adequate equipment and software programs led many professionals to use social networks and their personal cell phones instead.

Although several reports state that ICT successfully replaced face-to-face consultations²⁰20 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(2):e2020166., some population groups have difficulty accessing that technology³⁴34 James S, Ashley C, Williams A, Desborough J, Mcinnes S, Calma K, Mursa R, Stephen C, Halcomb EJ. Experiences of Australian primary healthcare nurses in using telehealth during COVID-19: a qualitative study. BMJ Open 2021; 11(8):e049095.^,4444 Breton M, Sullivan EE, Deville-Stoetzel N, McKinstry D, DePuccio M, Sriharan A, Deslauriers V, Dong A, McAlearney AS. Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts. BMC Fam Pract 2021; 22(1):192-205.. Some users lack the required equipment or the skills to use it, others suffer from visual, auditory or cognitive impairments that prevented them from using devices correctly⁴⁴44 Breton M, Sullivan EE, Deville-Stoetzel N, McKinstry D, DePuccio M, Sriharan A, Deslauriers V, Dong A, McAlearney AS. Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts. BMC Fam Pract 2021; 22(1):192-205.^,4545 Norman C, Wildman JM, Sowden S. COVID-19 at the Deep End: A Qualitative Interview Study of Primary Care Staff Working in the Most Deprived Areas of England during the COVID-19 Pandemic. Int J Environ Res Public Health 2021; 18(16):e8689.. Another concern is the security and confidentiality of data transmitted and stored on health professionals’ devices⁴⁶46 Garattini L, Badinella Martini M, Mannucci PM. Improving primary care in Europe beyond COVID-19: from telemedicine to organizational reforms. Intern Emerg Med 2021; 16(2):255-258..

Therefore, one comes to the conclusion that public policies need to be created that not only encourage the use of ICT in the health area, but also ensure that obstacles to access ICT can be overcome by those population groups, such as lack of access to the Internet, digital illiteracy, as well as physical and intellectual disabilities.

Organization of Work Processes

Workspaces were reorganized to meet the need for physical distancing among team members or to create separate environments for the care of symptomatic patients²¹21 Silva WRS, Duarte PO, Felipe DA, Sousa FOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19. Trab Educ Saude 2021; 19:e00330161.^,2323 Ghafri T Al, Al Ajmi F, Anwar H, Balushi LA, Balushi ZA, Fahdi FA, Lawati AA, Hashmi SA, Ghamari AA. Harthi MA, Kurup P, Lamki MA, Manji AA, Aharji AA, Harthi SA, Gibson E. The Experiences and Perceptions of Health-Care Workers During the COVID-19 Pandemic in Muscat, Oman: A Qualitative Study. J Prim Care Community Health 2020; 11:2150132720967514.^,2727 Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marciniowicz L, Reinhardt K, Skoglund I, Sundvall P, Vellinga A, Verheij TJM, Goossens H, Butler CC, Velden A, Snthierens S, Tonkin-Crine S. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract 2021; 71(709):e634-e642.^,3030 Bhatti S, Commisso E, Rayner J. A Rapid Primary Healthcare Response to COVID-19: An Equity-Based and Systems- Thinking Approach to Care Ensuring that No One Is Left Behind. Healthc Q 2020; 23(3):29-33.^,3131 Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, Olmen J. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract 2020; 21(1):255-261.^,4747 Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10(12):e043151.^,4848 Oliveira LMS, Gomes NP, Oliveira ES, Santos AA, Pedreira LC. Estratégia de enfrentamento para covid-19 na atenção primária à saúde: relato de experiência em Salvador-BA. Rev Gaucha Enferm 2021; 42:e20200138.. Patient appointment times were also changed, i.e., patients with respiratory symptoms or treated by specialized teams were booked at specific hours only²⁷27 Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marciniowicz L, Reinhardt K, Skoglund I, Sundvall P, Vellinga A, Verheij TJM, Goossens H, Butler CC, Velden A, Snthierens S, Tonkin-Crine S. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract 2021; 71(709):e634-e642.^,4747 Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10(12):e043151.^,4949 Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALDFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19. Rev Bras Med Familia Comun 2021; 16(43):2665.

50 Fernemark H, Skagerström J, Seing I, Hårdstedt M, Schildmeijer K, Nilsen P. Working conditions in primary healthcare during the COVID-19 pandemic: an interview study with physicians in Sweden. BMJ Open 2022; 12(2):e055035.

51 Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22(7):1338-1344.^-5252 Smyrnakis E, Symintiridou D, Andreou M, Dandoulakis M, Theodoropoulos E, Kokkali S, Manolaki C, Papageorgiou DI, Birtsou C, Paganas A, Stachteas P, Vlachopoulos N, Pagkozidis I, Zeimbekis A, Roka V, Giakoumis A, Kotsani M, Avakian I, Makridou E, Gavana M, Haidich A, Avgerinou C. Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study. BMC Fam Pract 2021; 22(1):174.. In addition, triage was introduced at clinic reception desks³⁰30 Bhatti S, Commisso E, Rayner J. A Rapid Primary Healthcare Response to COVID-19: An Equity-Based and Systems- Thinking Approach to Care Ensuring that No One Is Left Behind. Healthc Q 2020; 23(3):29-33. or by phone before people arrived at the clinics to check if they showed respiratory symptoms and to select those who required face-to-face consultations²⁵25 Ashcroft R, Donnelly C, Dancey M, Gill S, Lam S, Kourgiantakis T, Adamson K, Verrilli D, Dolovich L, Kirvan A, Mehta K, Sur D, Brown JB. Primary care teams' experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study. BMC Fam Pract 2021; 22(1):143-155.^,2727 Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana MN, Kinsman J, Lionis C, Marciniowicz L, Reinhardt K, Skoglund I, Sundvall P, Vellinga A, Verheij TJM, Goossens H, Butler CC, Velden A, Snthierens S, Tonkin-Crine S. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract 2021; 71(709):e634-e642.^,2929 Alboksmaty A, Kumar S, Parekh R, Aylin P. Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK - Qualitative assessment. PLoS One 2021; 16(3):e0248387.

30 Bhatti S, Commisso E, Rayner J. A Rapid Primary Healthcare Response to COVID-19: An Equity-Based and Systems- Thinking Approach to Care Ensuring that No One Is Left Behind. Healthc Q 2020; 23(3):29-33.^-3131 Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, Olmen J. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract 2020; 21(1):255-261.^,4747 Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10(12):e043151.^,5252 Smyrnakis E, Symintiridou D, Andreou M, Dandoulakis M, Theodoropoulos E, Kokkali S, Manolaki C, Papageorgiou DI, Birtsou C, Paganas A, Stachteas P, Vlachopoulos N, Pagkozidis I, Zeimbekis A, Roka V, Giakoumis A, Kotsani M, Avakian I, Makridou E, Gavana M, Haidich A, Avgerinou C. Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study. BMC Fam Pract 2021; 22(1):174..

Team meetings took place virtually⁵⁰50 Fernemark H, Skagerström J, Seing I, Hårdstedt M, Schildmeijer K, Nilsen P. Working conditions in primary healthcare during the COVID-19 pandemic: an interview study with physicians in Sweden. BMJ Open 2022; 12(2):e055035.^,5353 Fifolt M, White-Williams C, Shirey MR, Su W, Talley M. The Association of COVID-19 on Organizational Attitudes in Primary Care Among Interprofessional Practice Clinics. J Ambul Care Manage 2022; 45(2):95-104.

54 Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Ornstein KA, Federman AD. "At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing. J Am Geriatr Soc 2021; 69(2):300-306.^-5555 Mitchell S, Harrison M, Oliver P, Gardiner C, Chapman H, Khan D, Boyd K, Dale J, Barclay S, Mayland CR. Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey. Palliat Med 2022; 36(1):161-170. and messages were exchanged among professionals by means of electronic medical records or e-mail⁵³53 Fifolt M, White-Williams C, Shirey MR, Su W, Talley M. The Association of COVID-19 on Organizational Attitudes in Primary Care Among Interprofessional Practice Clinics. J Ambul Care Manage 2022; 45(2):95-104.^,5555 Mitchell S, Harrison M, Oliver P, Gardiner C, Chapman H, Khan D, Boyd K, Dale J, Barclay S, Mayland CR. Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey. Palliat Med 2022; 36(1):161-170.. Remote work was introduced, i.e., professionals were offered the possibility to provide patient care by means of electronic platforms from home⁴⁷47 Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10(12):e043151.^,5151 Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22(7):1338-1344.^,5656 Johnson C, Dupuis JB, Goguen P, Grenier G. Changes to telehealth practices in primary care in New Brunswick (Canada): A comparative study pre and during the COVID-19 pandemic. PLoS One 2021; 16(11):e0258839.. This strategy was also used when professionals who were part of risk groups needed to be removed from their workplace or had to quarantine⁵¹51 Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22(7):1338-1344..

Team composition was affected by the fact that professionals had to take turns at clinics to ensure physical distancing²¹21 Silva WRS, Duarte PO, Felipe DA, Sousa FOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19. Trab Educ Saude 2021; 19:e00330161. or were relocated to other locations to meet greater demands for professionals²²22 Fernandez M, Lotta G, Corrêa M. Desafios para a Atenção Primária à Saúde no Brasil: uma análise do trabalho das agentes comunitárias de saúde durante a pandemia de Covid-19. Trab Educ Saude 2021; 19:e210142.^,5757 Donnelly C, Ashcroft R, Bobbette N, Mills C, Mofina A, Tran T, Vader K, Williams A, Gill S, Miller J. Interprofessional primary care during COVID-19: a survey of the provider perspective. BMC Fam Pract 2021; 22(1):31-43..

While some health care workers were professionally limited by the pandemic, other professional categories, e.g. nurses, increased their scope of action and autonomy, including the right to prescribe certain medications⁵⁵55 Mitchell S, Harrison M, Oliver P, Gardiner C, Chapman H, Khan D, Boyd K, Dale J, Barclay S, Mayland CR. Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey. Palliat Med 2022; 36(1):161-170.^,5858 Xu Z, Ye Y, Wang Y, Qian Y, Pan J, Lu Y, Fang L. Primary Care Practitioners' Barriers to and Experience of COVID-19 Epidemic Control in China: a Qualitative Study. J Gen Intern Med 2020; 35(11):3278-3284..

Division of flows of patients showing respiratory symptoms or with a confirmed COVID19 diagnosis was a widely used strategy to reduce COVID-19 infection risks⁴4 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(8):e00149720.. It was noticed that reorganization of service locations occurred in different ways, according to local realities. Several municipalities in Brazil chose to install tents outside their clinics, while others allocated specific clinics to treat respiratory symptoms⁸8 Giovanella L, Martufi V, Ruiz DC, Mendonça MHM, Bousquat A, Aquino R, Medina MG. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate 2021; 45(130):748-762..

Thus, the present review confirms the plasticity of PHC, allowing to permanently reorganize work processes according to the needs of every stage of the pandemic. That kind of plasticity requires great planning capacity and flexibility from managers to quickly meet new needs, which also requires that they have to be able to accept the different alternatives designed by workers to reorganize work processes.

Non-COVID Chronic Diseases

To reduce the demand for health services by chronically ill patients, the interval between consultations was increased for patients showing a stable clinical condition³²32 Wilson G, Windner Z, Dowell A, Toop L, Savage R, Hudson B. Navigating the health system during COVID-19: primary care perspectives on delayed patient care. N Z Med J 2021; 134(1546):17-27.. Likewise, the validity of medical prescriptions was extended so that users could buy their medication without having to make a new appointment⁴⁹49 Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALDFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19. Rev Bras Med Familia Comun 2021; 16(43):2665. and the quantity of medications was increased as well⁵¹51 Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22(7):1338-1344.^,5961. Some clinics started to deliver prescriptions for chronic and clinically stable patients to their family members ⁴⁹49 Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALDFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19. Rev Bras Med Familia Comun 2021; 16(43):2665. or to send them directly to pharmacies using computerized prescription systems³⁵35 Koster ES, Philbert D, Bouvy ML. Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies. Res Soc Adm Pharm 2021; 17(1):2002-2004.^,5252 Smyrnakis E, Symintiridou D, Andreou M, Dandoulakis M, Theodoropoulos E, Kokkali S, Manolaki C, Papageorgiou DI, Birtsou C, Paganas A, Stachteas P, Vlachopoulos N, Pagkozidis I, Zeimbekis A, Roka V, Giakoumis A, Kotsani M, Avakian I, Makridou E, Gavana M, Haidich A, Avgerinou C. Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study. BMC Fam Pract 2021; 22(1):174.^,6262 Kurotschka PK, Serafini A, Demontis M, Serafini A, Mereu A, Moro MF, Carta MG, Ghirotto L. General Practitioners' Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study. Front Public Health 2021; 9:623904.. Others chose to send patients SMS messages to remind them that certain medications were running out or to schedule and organize delivery of medication³⁵35 Koster ES, Philbert D, Bouvy ML. Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies. Res Soc Adm Pharm 2021; 17(1):2002-2004.^,6161 Steiner RJ, Zapata LB, Curtis KM, Whiteman MK, Brittain AW, Tromble E, Keys KR, Fasula AM. COVID-19 and Sexual and Reproductive Health Care: Findings From Primary Care Providers Who Serve Adolescents. J Adolesc Health 2021; 69(3):375-382.. Three studies state that some clinics delivered medication to patient homes so that these could spare the trip and thus avoided crowding at clinics³⁵35 Koster ES, Philbert D, Bouvy ML. Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies. Res Soc Adm Pharm 2021; 17(1):2002-2004.^,5959 Crowley T, Kitshoff D, Lange-Cloete F, Baron J, Lange S, Young C, Esterhuizen T, Couper I. Reorganisation of primary care services during COVID-19 in the Western Cape, South Africa: Perspectives of primary care nurses. South African Fam Pract 2021; 63(1):a5358.^,6363 Brey Z, Mash R, Goliath C, Roman D. Home delivery of medication during Coronavirus disease 2019, Cape Town, South Africa: Short report. African J Prim Heal Care Fam Med 2020; 12(1):a2449.. Two studies report the delivery of oximeters, capillary blood glucose devices, sphygmomanometers and PT/INR measurement kits for remote monitoring of users⁵⁴54 Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Ornstein KA, Federman AD. "At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing. J Am Geriatr Soc 2021; 69(2):300-306.^,6464 Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract 2021; 22(1):237..

Despite changes in work organization and strategies to reduce the number of chronically ill patients coming to clinics, three studies mention initiatives that aimed at keeping up care services for priority groups, e.g. pregnant women, and actions such as childcare²¹21 Silva WRS, Duarte PO, Felipe DA, Sousa FOS. A gestão do cuidado em uma unidade básica de saúde no contexto da pandemia de Covid-19. Trab Educ Saude 2021; 19:e00330161.^,4747 Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10(12):e043151.^,4949 Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALDFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19. Rev Bras Med Familia Comun 2021; 16(43):2665..

Interruption of care services, especially at the beginning of the pandemic, accompanied by a significant drop in the number of consultations particularly affected chronically ill people whose health condition was more likely to worsen or who were prone to developing serious forms of COVID-19⁸8 Giovanella L, Martufi V, Ruiz DC, Mendonça MHM, Bousquat A, Aquino R, Medina MG. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate 2021; 45(130):748-762.. It is known that death related to other diseases during an epidemic increases if these are no longer properly managed⁸8 Giovanella L, Martufi V, Ruiz DC, Mendonça MHM, Bousquat A, Aquino R, Medina MG. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate 2021; 45(130):748-762..

Arrangements developed for the care of chronic health conditions were mostly based on a strategy that involved remote monitoring of these patients and reducing their need to go to clinics. Domiciliary consultations by doctors and nurses, supported by community health agents (CHA) allows monitoring high-risk patients, as well as those who lack access to ICT¹³13 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(6):e00104120.. The work of CHA gains relevance as they also identify users living in extreme poverty, in situations of food insecurity and vulnerable groups, and as they support isolation strategies⁶⁵65 Maciel FBM, Santos HLPC, Carneiro RAS, Souza EA, Prado NMBL, Teixeira CFS. Agente comunitário de saúde: reflexões sobre o processo de trabalho em saúde em tempos de pandemia de Covid-19. Cien Saude Colet 2020; 25:4185-4195..

Low attendance at consultations by chronically ill people was noticed, which was either due to access constraints, a reduced number of available consultations, or even fear of contamination by the virus⁵²52 Smyrnakis E, Symintiridou D, Andreou M, Dandoulakis M, Theodoropoulos E, Kokkali S, Manolaki C, Papageorgiou DI, Birtsou C, Paganas A, Stachteas P, Vlachopoulos N, Pagkozidis I, Zeimbekis A, Roka V, Giakoumis A, Kotsani M, Avakian I, Makridou E, Gavana M, Haidich A, Avgerinou C. Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study. BMC Fam Pract 2021; 22(1):174.. Indeed, fear of contracting COVID-19 at doctors’ offices made many people avoid even virtual appointments, as they feared being referred to offices or hospitals²⁹29 Alboksmaty A, Kumar S, Parekh R, Aylin P. Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK - Qualitative assessment. PLoS One 2021; 16(3):e0248387.. Low attendance at consultations, associated with the interruption of various outpatient or hospital medical procedures may have resulted in excessive demand for health services in the post-pandemic period and a more effective participation of PHC in coordinating care services offered to these people⁶⁶66 Veremu M, Sohail A, McMaster D. COVID-19: exploring out-of-hospital solutions to increased service demand. Fam Pract 2021; 38(5):694-695..

A large part of care arrangements and innovations aimed at chronically ill people also resulted from acts on an ad hoc basis. These arrangements did not cover PHC entirely and therefore, it is fundamental to share successful experiences that may leverage solutions needed to meet the post-COVID demand.

Final considerations

Although several healthcare journals have been publishing studies on COVID-19 in a fast way, the research-publication cycle is slow and most of the studies selected for our review relied on data collected at the onset of the pandemic. This fact may have influenced the findings of this review, as arrangements developed at the beginning of the pandemic were intended to meet the need of social distancing and care for symptomatic people by avoiding putting too many patients at risk of infection⁴⁶46 Garattini L, Badinella Martini M, Mannucci PM. Improving primary care in Europe beyond COVID-19: from telemedicine to organizational reforms. Intern Emerg Med 2021; 16(2):255-258., given the fact that vaccines were not yet available. Several arrangements made after this initial period may have been extremely important for care of users in PHC, but they have not yet been described by scientific literature, such as issues related to vaccination against the COVID-19 virus or care of patients suffering from “long COVID”.

The adopted publication search strategy was not restricted in terms of study location or publication language and contributed to increase review scope and to outline a broad overview of the main care arrangements in PHC. However, a considerable number of articles used data from locations whose public health system differ from the Brazilian public health system. Therefore, many results need to be interpreted with caution, since they cannot necessarily be applied to Brazilian reality.

PHC actively helped control the COVID-19 pandemic and several innovations were made in care arrangements and forms, despite the fact that many services suspended their activities, especially at the beginning of the pandemic. The use of different forms of ICT gained great prominence, not only for people with respiratory symptoms and for chronically ill patients, but also for those with other clinical complications. Although some strategies aimed to monitor chronically ill patients by PHC teams and remote care may have contributed to minimize their health issues, the decrease in the number of visits performed during this period may have resulted in an increased demand in PHC in the post-pandemic years.

The challenge that now emerges is to maintain, institutionalize and formalize innovations and arrangements created during the pandemic in the form of daily practices to qualify health care practices.

References

Publication Dates

History