ABSTRACT

OBJECTIVE

Mapping available scientific evidence on the organization of primary health care services and professionals during the Covid-19 pandemic.

METHODS

This is a scoping review that followed the Joanna Briggs Institute method. Articles published in Portuguese, Spanish, and English from January 2020 to January 2021 in the CINAHL, Lilacs, Medline, PubMed, and Web of Science databases were included.

RESULTS

We selected 24 articles that presented the reorganization of primary health care services and professionals to care suspected or confirmed Covid-19 cases. Coordination measures to tackle this disease in primary health care help to control its infection, especially by the active search for respiratory symptoms, the detection of new cases, and the monitoring of confirmed cases.

CONCLUSION

This study presents an overview of how primary health care services and professionals organized themselves to tackle the Covid-19 pandemic, addressing adjustments in infrastructure and care flows, such as establishing specific Covid-19 care units, separating infected and non-infected patients, using telemedicine as an alternative modality of care, and monitoring cases by applications and phone.

Primary Health Care, organization & administration; COVID-19, prevention & control; Health Human Resource Training; Review

INTRODUCTION

In order to tackle the pandemic of the new coronavirus, health systems worldwide had to adjusted themselves to provide different responses against its infection, prevent its spread, and reduce the sequelae caused by Covid-19 in the population. Due to the high transmissibility rate of this disease, it rapidly spread worldwide, resulting, from the beginning of the pandemic to the first quarter of 2022, in more than 500 million confirmed cases and more than six million deaths worldwide¹1. World Health Organization. Coronavirus disease (COVID-19) pandemic. Geneva (CH): WHO; 2021 [cited 2022 Apr 17]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/emergencies/diseases... . During the same period, Brazil had more than 30 million confirmed cases and the number of deaths has already exceeded 660,000²2. Ministério da Saúde (BR). Painel de casos de doença pelo coronavírus 2019 (COVID-19) no Brasil pelo Ministério da Saúde. Brasília, DF; 2022 [cited 2022 Apr 17]. Available from: https://covid.saude.gov.br/
https://covid.saude.gov.br/... .

The pandemic posed challenges for health systems, showing their weaknesses by exposing chronic funding and management problems³3. Tabish SA. COVID-19 pandemic: emerging perspectives and future trends. J Public Health Res. 2020;9(1):1786. https://doi.org/10.4081/jphr.2020.1786
https://doi.org/10.4081/jphr.2020.1786... . Preparing these systems to tackle emerging infectious diseases, by evidence-based planning and strategies and coordination between all segments of a system and the government, is important.

In Brazil, primary health care (PHC) stands out since it is generally the main gateway for health services in the Brazilian Unified Health System (SUS). PHC is organized in order to solve most health problems of individuals and their families and played a fundamental role in the fight against the pandemic, as most infected people developed a mild form of the disease, which allowed their follow-up to be performed at this level of care⁴4. World Health Organization, Regional Office for the Western Pacific Region. Role of primary care in the COVID-19 Response: interim guidance. Manila (PH); 2021 [cited 2022 Apr 17]. Available from: https://apps.who.int/iris/handle/10665/331921
https://apps.who.int/iris/handle/10665/3... .

Considering actions to be developed to tackle Covid-19, especially in PHC, the knowledge of the territory, the access, the link between patients and health teams, the integrality of care, the monitoring of vulnerable families and suspected and mild cases of the disease allow the development of essential strategies to contain the pandemic and prevent the worsening of Covid-19⁷7. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. What is the role of Primary Health Care in the COVID-19 pandemic? Epidemiol Serv Saude. 2020;29(2):e2020166. https://doi.org/10.5123/S1679-49742020000200024
https://doi.org/10.5123/S1679-4974202000... .

In Brazil, PHC remains a central point in the organization of the SUS, thus, strengthening and organizing it is necessary, in order to make it a pillar to tackle Covid-19, due to its capacity to link, manage, and monitor cases during the pandemic, and resume its routines after the pandemic, based on the context of the Country as a whole⁷7. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. What is the role of Primary Health Care in the COVID-19 pandemic? Epidemiol Serv Saude. 2020;29(2):e2020166. https://doi.org/10.5123/S1679-49742020000200024
https://doi.org/10.5123/S1679-4974202000... ,⁸8. Conselho Nacional de Secretários de Saúde. Guia orientador para o enfrentamento da pandemia COVID-19 na Rede de Atenção à Saúde. 2. ed. Brasília, DF: CONASS; 2020..

Thus, PHC is essential to tackle Covid-19 worldwide, developing educational, preventive, health-promoting, care, and administrative actions. All health professionals and managers are responsible for organizing PHC in order to provide effective services and it must be done not only in health units, but throughout Brazil and at home.

Studies on the evolution and treatment of Covid-19, as well as its vaccines, have been published, however, mapping scientific evidence on studies on the organization of PHC health services and professionals and its effect on tackling the pandemic is necessary.

Thus, this study shows gaps on the topic and reflects on the organization of actions to mitigate Covid-19 at this level of care, allowing the planning of strategies to tackle this disease in order to provide a resolutive and quality care of the population. Therefore, this study aimed to map available scientific evidence on the organization of PHC services and professionals during the Covid-19 pandemic.

METHODS

This is a scoping review that followed the Joanna Briggs Institute (JBI) method: (1) identification of the research question, (2) identification of relevant articles, (3) selection of articles, (4) data extraction, (5) separation, summarization, and reporting of results, and (6) dissemination of results⁹9. Aromataris E, Munn Z, editors. JBI manual for evidence synthesis. Adelaide (AU): JBI Faculty of Health and Medical Sciences, the University of Adelaide; 2020 [cited 2022 Apr 17]. Available from: https://synthesismanual.jbi.global
https://synthesismanual.jbi.global... .

For the search, the JBI method, which consists of an acronym (PCC)—”P” for population, “C” for concept, and “C” for context—was used. This study considered “P” health professionals, “C” primary health care, and “C” organization and Covid-19, and it was developed based on the question: How was the organization of PHC services and health professionals during the Covid-19 pandemic?

Articles were searched in the following databases: US National Library of Medicine – National Institutes of Health (PubMed), Medical Literature Analysis and Retrieval System Online (Medline), Institute for Scientific Information (Web of Science), Literatura Latino-Americana em Ciências da Saúde (Lilacs – Latin American Literature in Health Sciences), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles were searched from March to May 2021 using keywords and their synonyms—organization, care, PHC, Covid-19, and health professionals—which were included in the Descritor em Ciências da Saúde (DeCS – Health Sciences Descriptors) and the Medical Subject Headings (MeSH) in different languages (Box 1).

Primary articles in Portuguese, English, and Spanish, published from January 1, 2020, to January 31, 2021, and indexed in the aforementioned databases were included. Protocols, editorials, systematic reviews, and articles with titles and abstracts that did not answer the research question, as well as information from websites and reported by the media, were excluded.

Later, references were exported to the StArt (State of the Art through Systematic Review) application for the selection of articles on two levels. The first selection was performed by the reading of titles and abstracts, followed by the reading of the full text. StArt was developed by the Laboratório de Pesquisa em Engenharia de Software (LaPES – Software Engineering Research Laboratory) of the Universidade Federal de São Carlos (UFSCar)¹⁰10. Fabbri S, Silva C, Hernandes E, Octaviano F, Di Thommazo A, Belgamo A. Improvements in the StArt tool to better support the systematic review process. In: Proceedings of the 20th International Conference on Evaluation and Assessment in Software Engineering (EASE ’16); 2016 June; Limerick, Ireland. p.1-5..

Eligible articles were fully recovered and evaluated by two researchers. In both phases, divergences were discussed until reaching a consensus and making the final selection—in this last moment, a third researcher participated. This study was based on Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR)¹¹11. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... .

Authorship, journal name, country where the study was performed, country of publication, study design, main results, and gaps were the relevant information collected from each selected article. Results on bibliometric aspects that answer the research question are presented in boxes and in the main text of this scoping review.

RESULTS

We found 1,262 articles in the databases used, however, we excluded 374 because they were duplicates, 833 after reading their titles and abstracts, and 31 after reading the full text. Thus, we studied 24 articles addressing the organization of PHC services and health professionals during the Covid-19 pandemic (Figure).

All articles included in this study were published from January 1, 2020, to January 31, 2021. Five of them (21%) were performed in Brazil, four (17%) in the United States, two (8%) in Oman, the United Kingdom, Italy, and Belgium, and one (4%) in Spain, India, Flanders, Saudi Arabia, Botswana, France, and Iceland. Regarding languages, 20 (83%) articles were published in English and four (17%) in Portuguese.

Among these 24 articles, nine were experience reports, five were observational studies, four were descriptive studies, two were cross-sectional studies, two were qualitative studies, and two were case studies (Box 2).

The articles studied presented a global picture of how PHC professionals and services organized themselves to tackle the Covid-19 pandemic, especially by the use of technologies and telemedicine. In total, 17 (71%) articles addressed this alternative modality of care and the monitoring of cases by applications, phone, and online platforms (Box 2).

Moreover, 13 (54%) articles addressed adjustments in infrastructure and care flows, such as the adoption of specific Covid-19 care units, the separation of infected and non-infected patients in health units, and changes in the work process and infrastructure (Box 2).

Three (12.5%) articles studied the importance of health education on Covid-19 for the community and health teams and three (12.5%) analyzed the care of chronic patients during the pandemic. Two (8.5%) articles assessed the organization of PHC services and professionals based on previous experiences, such as the H1N1 pandemic (Box 2).

DISCUSSION

The 24 articles selected in this study addressed the reorganization of PHC services and professionals and the surveillance in the monitoring of Covid-19 cases for the care of suspected or confirmed cases.

In March 2020, after the declaration of community transmission of this disease throughout Brazil, the Secretariat of Health Surveillance of the Ministry of Health adapted the Sistema de Vigilância de Síndromes Respiratórias Agudas (SRAG – Acute Respiratory Syndromes Surveillance System), aiming to guide the Sistema Nacional de Vigilância em Saúde (SNVS – National Health Surveillance System) during the simultaneous circulation of SARS-CoV-2, influenza, and other respiratory viruses, within the scope of the Emergência em Saúde Pública de Importância Nacional (ESPIN – Public Health Emergency of National Importance)¹²12. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 – COVID-19. Brasília, DF; 2021 [cited 2022 Apr 9]. Available from: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/guia-de-vigilancia-epidemiologica-covid-19/view
https://www.gov.br/saude/pt-br/coronavir... .

This context shows the importance of the role of health surveillance in the notification, investigation, and monitoring of severe and confirmed Covid-19 cases¹³13. Jesus AM, Oliveira KNR, Silva MPF, Matos RB, Dias CFMA. Rede de vigilância no monitoramento da Covid-19 na Bahia, Brasil, 2020. Rev Baiana Saude Publica. 2021;45 Nº Espec 1:62-78.. Health surveillance actions are essential for the PHC organization in this new scenario, by the development of actions that enable the early identification of suspected cases, immediate notification, active search for contacts, reinforcement of home isolation, health education, and support to vulnerable groups in Brazil¹⁴14. Giovanella L, Martufi V, Mendoza DCR, Mendonça MHM, Bousquat AEM, Aquino R, et al. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate. 2020;44 Nº Espec 4):1-21. https://doi.org/10.1590/0103-11042020E410
https://doi.org/10.1590/0103-11042020E41... .

The Covid-19 pandemic increased the demand for care in the SUS, which made the Brazilian Ministry of Health reinforce the need for organization of the care network and care flows both for people with flu-like diseases, including Covid-19, and who needed follow-up for other health conditions¹²12. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 – COVID-19. Brasília, DF; 2021 [cited 2022 Apr 9]. Available from: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/guia-de-vigilancia-epidemiologica-covid-19/view
https://www.gov.br/saude/pt-br/coronavir... .

Thus, during the Covid-19 pandemic in Brazil, the main strategy of PHC to tackle this disease was reorganizing the work process of health professionals, especially by health education activities, as it builds knowledge to provide self-care¹⁵15. Geraldo SM, Farias SJM, Sousa FOS. A atuação da Atenção Primária no contexto da pandemia da COVID-19 no Brasil. Res Soc Dev. 2021;10(8):e42010817359. https://doi.org/10.33448/rsd-v10i8.17359
https://doi.org/10.33448/rsd-v10i8.17359... . All countries had to reorganize and strengthen the responsiveness of PHC services, according to their public policies, and ensure care for other health demands of the population¹⁶16. Prado NMBL, Rossi TRA, Chaves SCL, Barros SG, Magno L, Santos HLPC, et al. The international response of primary health care to COVID-19: document analysis in selected countries. Cad Saude Publica. 2020;36(12):e00183820. https://doi.org/10.1590/0102-311X00183820
https://doi.org/10.1590/0102-311X0018382... .

Moreover, Brazil constantly updated epidemiological surveillance guides to direct the fight against Covid-19¹²12. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 – COVID-19. Brasília, DF; 2021 [cited 2022 Apr 9]. Available from: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/guia-de-vigilancia-epidemiologica-covid-19/view
https://www.gov.br/saude/pt-br/coronavir... . The Brazilian Ministry of Health published the Protocolo de Manejo Clínico do Coronavírus (Covid-19) na Atenção Primária à Saúde (Covid-19 Clinical Management in Primary Health Care Protocol), recommending the reorganization of PHC services and the work process to tackle the pandemic. This protocol established measures to prevent infection in health services, models for stratification of the severity of suspected cases, actions for therapeutic follow-up and home isolation of mild cases, measures for stabilization and referral to services of greater complexity, and actions to promote community prevention measures¹⁷17. Ministério da Saúde (BR), Secretaria de Atenção Primária à Saúde. Protocolo de manejo clínico do coronavírus (COVID-19) na Atenção Primária à Saúde - Versão 9. Brasília (DF); 2020 [cited 2022 Apr 17]. Available from: https://docs.bvsalud.org/biblioref/2020/05/1095920/20200504-protocolomanejo-ver09.pdf
https://docs.bvsalud.org/biblioref/2020/... .

The reorganization of the physical structure of PHC services was one of the main strategies to reduce risks of infection in health units, speed up services—avoiding contact between patients with and without suspected Covid-19—and protect professionals, maximizing the efficiency of the services provided.

Studies performed in Brazil, Belgium, Iceland, and the USA adapted health units to maintain physical distancing, adopted the immediate identification of symptomatic cases at reception, limited the number of companions, separated rooms for symptomatic and asymptomatic patients, and reorganized the care of priority groups assisted by the service¹⁸18. Krist AH, DeVoe JE, Cheng A, Ehrlich T, Jones SM. Redesigning primary care to address the COVID-19 pandemic in the midst of the pandemic. Ann Fam Med. 2020;18(4):349-54. https://doi.org/10.1370/afm.2557
https://doi.org/10.1370/afm.2557... .

In Diadema, SP, the health management decentralized the care to respiratory symptomatic patients in all PHC units, considering the capillarity of PHC with family health teams. Thus, all services at this level of care adopted this demand²⁴24. Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19: a experiência de Diadema, SP. Rev Bras Med Fam Comunidade. 2021;16(43):2665. https://doi.org/10.5712/rbmfc16(43)2665
https://doi.org/10.5712/rbmfc16(43)2665... .

In Florianópolis, SC, Sobral, CE, and Belo Horizonte, MG, health units with adequate physical space also organized care flows separately: they treated suspected and confirmed Covid-19 patients in different places from other patients²⁵25. Silveira JPM, Zonta R. Experiência de reorganização da APS para o enfrentamento da COVID-19 em Florianópolis. APS Rev. 2020;2(2):91-6. https://doi.org/10.14295/aps.v2i2.122
https://doi.org/10.14295/aps.v2i2.122... .

On the other hand, one or more specific health units centralized the care of respiratory symptomatic patients. The organization of these services presented similarities, such as the respect for the instructions to patients on personal hygiene care and use of masks and the redesign of physical spaces to respect physical distancing²⁸28. Jacobson NA, Nagaraju D, Miller JM, Bernard ME. COVID Care Clinic: a unique way for family medicine to care for the community during the SARS-CoV-2 (COVID-19) pandemic. J Prim Care Community Health. 2020;11:2150132720957442. https://doi.org/10.1177/2150132720957442
https://doi.org/10.1177/2150132720957442... .

England created specific care units for Covid-19 patients and those who were unable to go to a health unit or did not need hospital care were monitored at home³⁰30. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. J R Soc Med. 2020;113(6):208-10. https://doi.org/10.1177/0141076820931452
https://doi.org/10.1177/0141076820931452... .

In Rochester, Minnesota, USA, this same strategy was adopted to avoid contact between confirmed or suspected Covid-19 patients and other patients. Of the five health units in this city, one was adjusted to exclusively care for Covid-19 patients or people with symptoms of respiratory problems. Initially, they adopted phone screening to evaluate if patients needed hospital care or could be cared at the Covid-19 unit²⁸28. Jacobson NA, Nagaraju D, Miller JM, Bernard ME. COVID Care Clinic: a unique way for family medicine to care for the community during the SARS-CoV-2 (COVID-19) pandemic. J Prim Care Community Health. 2020;11:2150132720957442. https://doi.org/10.1177/2150132720957442
https://doi.org/10.1177/2150132720957442... .

Considering the need to adjust face-to-face care in health units in the pandemic context, strategies for remote care emerged as an alternative to monitor both Covid-19 and other patients⁶6. Cabral ERM, Bonfada D, Melo MC, Cesar ID, Oliveira REM, Bastos TF, et al. Contributions and challenges of the Primary Health Care across the pandemic COVID-19. InterAm J Med Health. 2020;3:e202003012. https://doi.org/10.31005/iajmh.v3i0.87
https://doi.org/10.31005/iajmh.v3i0.87... ,¹⁴14. Giovanella L, Martufi V, Mendoza DCR, Mendonça MHM, Bousquat AEM, Aquino R, et al. A contribuição da Atenção Primária à Saúde na rede SUS de enfrentamento à Covid-19. Saude Debate. 2020;44 Nº Espec 4):1-21. https://doi.org/10.1590/0103-11042020E410
https://doi.org/10.1590/0103-11042020E41... ,²⁴24. Cirino FMSB, Aragão JB, Meyer G, Campos DS, Gryschek ALFPL, Nichiata LYI. Desafios da atenção primária no contexto da COVID-19: a experiência de Diadema, SP. Rev Bras Med Fam Comunidade. 2021;16(43):2665. https://doi.org/10.5712/rbmfc16(43)2665
https://doi.org/10.5712/rbmfc16(43)2665... ,³¹31. Engstrom E, Melo E, Giovanella L, Mendes A, Grabois V, Mendonça MHM. Recomendações para a organização da Atenção Primária à Saúde no SUS no enfrentamento da COVID-19. Rio de Janeiro: Fiocruz; 2020 [cited 2022 Apr 17]. (Série Linha de Cuidado Covid-19 na Rede de Atenção à Saúde). Available from: https://www.arca.fiocruz.br/bitstream/icict/41404/2/RecomendacoesAPSEnfrentamentoCovid-19.pdf
https://www.arca.fiocruz.br/bitstream/ic... . Thus, telemedicine and remote monitoring were included in the routine of health professionals, aiming to decrease the number of patients in services and refer them to health units only when necessary. These measures aimed to reduce the circulation of SARS-CoV-2²⁰20. Fernandes LMM, Pacheco RA, Fernandez M. How a Primary Health Care Clinic in Brazil faces coronavirus treatment within a vulnerable community: the experience of the Morro da Conceição area in Recife. NEJM Catal Innov Care Deliv. 2020;1(5). https://doi.org/10.1056/CAT.20.0466
https://doi.org/10.1056/CAT.20.0466... .

In Australia, PHC started using telemedicine and call centers to screen people with respiratory symptoms, as well as developing a national network of complementary respiratory units. Moreover, health professionals participated in online trainings and health protection measures for Aboriginal communities and the population of the Torres Strait islands were disclosed⁴²42. Desborough J, Dykgraaf SH, Toca L, Davis S, Roberts L, Kelaher C, et al. Australia’s national COVID-19 primary care response. Med J Aust. 2020;213(3):104-6. https://doi.org/10.5694/mja2.50693
https://doi.org/10.5694/mja2.50693... .

In the United Kingdom, the number of remote appointments doubled while face-to-face appointments and home visits decreased. In total, three-quarters of PHC patients were remotely cared³⁰30. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. J R Soc Med. 2020;113(6):208-10. https://doi.org/10.1177/0141076820931452
https://doi.org/10.1177/0141076820931452... ,³⁸38. Joy M, McGagh D, Jones N, Liyanage H, Sherlock J, Parimalanathan V, et al. Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK. Br J Gen Pract. 2020;70(697):e540-7. https://doi.org/10.3399/bjgp20X710933
https://doi.org/10.3399/bjgp20X710933... . In Iceland, the number of phone or online appointments increased by 127% and the number of remote medicine prescriptions and appointments also increased¹⁸18. Krist AH, DeVoe JE, Cheng A, Ehrlich T, Jones SM. Redesigning primary care to address the COVID-19 pandemic in the midst of the pandemic. Ann Fam Med. 2020;18(4):349-54. https://doi.org/10.1370/afm.2557
https://doi.org/10.1370/afm.2557... . France, Italy, and Belgium also presented this increasing trend, since most general physicians adapted their activities to the remote modality¹⁹19. Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. PLoS One. 2020;15(8):e0237629. https://doi.org/10.1371/journal.pone.0237629
https://doi.org/10.1371/journal.pone.023... ,²⁹29. Saint-Lary O, Gautier S, Le Breton J, Gilberg S, Frappé P, Schuers M, et al. How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey. BMJ Open. 2020;10(12):e042119. https://doi.org/10.1136/bmjopen-2020-042119
https://doi.org/10.1136/bmjopen-2020-042... ,⁴⁰40. Bressy S, Zingarelli EM. Technological devices in COVID-19 primary care management: the Italian experience. Fam Pract. 2020;37(5):725-6. https://doi.org/10.1093/fampra/cmaa055
https://doi.org/10.1093/fampra/cmaa055... .

In Italy, the monitoring and follow-up of Covid-19 patients was performed remotely, by social networking applications, and twice a day, including the monitoring of the vital signs of patients, which were measured by smartphones. In cases of difficulty to monitor vital signs by technological devices, patients could borrow a pulse oximeter to check their saturation and heart rate at home⁴⁰40. Bressy S, Zingarelli EM. Technological devices in COVID-19 primary care management: the Italian experience. Fam Pract. 2020;37(5):725-6. https://doi.org/10.1093/fampra/cmaa055
https://doi.org/10.1093/fampra/cmaa055... .

Although telemedicine allows the continuity of care remotely, this change can hinder the practice of general physicians due to the loss of non-verbal communication, the limited capacity of some patients to articulate their needs, and the association between intercultural communication and language problems, which are barriers in care³⁴34. Verhoeven V, Tsakitzidis G, Philips H, Van Royen P. Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs. BMJ Open. 2020;10(6):e039674. https://doi.org/10.1136/bmjopen-2020-039674
https://doi.org/10.1136/bmjopen-2020-039... .

A study performed with the older adults cared by PHC in the United Kingdom showed that health professionals must be aware that remote appointments, especially in the case of video calls, may represent an additional barrier in the care of vulnerable groups, who have limited access to the Internet, smartphones, and other technologies³⁸38. Joy M, McGagh D, Jones N, Liyanage H, Sherlock J, Parimalanathan V, et al. Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK. Br J Gen Pract. 2020;70(697):e540-7. https://doi.org/10.3399/bjgp20X710933
https://doi.org/10.3399/bjgp20X710933... .

The Covid-19 pandemic promoted innovation in the care provided by PHC, since health units had to adapt themselves to physical distancing measures. However, PHC must evaluate the efficiency of remote care and identify the possible difficulties of a group in the use of the necessary technologies.

In the scope of PHC, education actions became stronger in the care provided by health professionals to limit the spread of Covid-19²²22. Dias EG, Ribeiro DRSV. Manejo do cuidado e a educação em saúde na atenção básica na pandemia do Coronavírus. J Nurs Health. 2020;10(4):20104020.,²³23. Vieira DS, Sá PC, Torres RC, Oliveira FT, Rocha KRSL, Vasconcelos TLC, et al. Planejamento da enfermagem frente à covid-19 numa estratégia de saúde da família: relato de experiência. Saude Coletiva (Barueri). 2020;10(54):2729-40. https://doi.org/10.36489/saudecoletiva.2020v10i54p2729-2740
https://doi.org/10.36489/saudecoletiva.2... ,³²32. Al Ghafri T, Al Ajmi F, Anwar H, Al Balushi L, Al Balushi Z, Al Fahdi F, et al. 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. https://doi.org/10.1177/2150132720967514
https://doi.org/10.1177/2150132720967514... ,³⁴34. Verhoeven V, Tsakitzidis G, Philips H, Van Royen P. Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs. BMJ Open. 2020;10(6):e039674. https://doi.org/10.1136/bmjopen-2020-039674
https://doi.org/10.1136/bmjopen-2020-039... ,⁴³43. Duarte RB, Medeiros LMF, Araújo MJAM, Cavalcante ASP, Souza EC, Alencar OM, et al. Agentes Comunitários de Saúde frente à COVID-19: vivências junto aos profissionais de enfermagem. Enferm Foco. 2020;11 (1 Nº Espec):252-6. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3597
https://doi.org/10.21675/2357-707X.2020.... ,⁴⁴44. Ximenes Neto FRG, Araújo CRC, Silva RCC, Ribeiro MA, Sousa LA, Serafim TF, et al. Coordenação do cuidado, vigilância e monitoramento de casos da COVID-19 na Atenção Primária à Saúde. Enferm Foco. 2020;11(1 Nº Espec):239-45. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3682
https://doi.org/10.21675/2357-707X.2020.... . We highlight the difficulty of dealing with community rumors and misleading information, which directly affected the care process during the pandemic. Thus, integrating technology support and disseminating reliable guidelines is important³²32. Al Ghafri T, Al Ajmi F, Anwar H, Al Balushi L, Al Balushi Z, Al Fahdi F, et al. 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. https://doi.org/10.1177/2150132720967514
https://doi.org/10.1177/2150132720967514... .

Adherence to prevention measures against Covid-19 is related to health education actions carried out by health professionals. In this sense, digital technologies are important to disseminate information about the prevention of this disease by social networks. They also reinforce the fundamental role of community health agents in health education, especially in the fight against fake news and the mediation between PHC and the community²²22. Dias EG, Ribeiro DRSV. Manejo do cuidado e a educação em saúde na atenção básica na pandemia do Coronavírus. J Nurs Health. 2020;10(4):20104020.,⁴³43. Duarte RB, Medeiros LMF, Araújo MJAM, Cavalcante ASP, Souza EC, Alencar OM, et al. Agentes Comunitários de Saúde frente à COVID-19: vivências junto aos profissionais de enfermagem. Enferm Foco. 2020;11 (1 Nº Espec):252-6. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3597
https://doi.org/10.21675/2357-707X.2020.... .

In a Brazilian municipality, family health teams, along with community agents, carried out health education activities for the population. These actions aimed to guide the population on preventive measures against Covid-19 and disseminate epidemiological data by radio, sound cars, flyers, social networks, and phone. However, the number of suspected Covid-19 cases did not decrease, showing the importance of people’s adherence to the prevention measures¹⁹19. Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. PLoS One. 2020;15(8):e0237629. https://doi.org/10.1371/journal.pone.0237629
https://doi.org/10.1371/journal.pone.023... . For health education actions to achieve their objectives, developing different strategies to overcome social and cultural barriers that influence the choices of individuals is necessary²²22. Dias EG, Ribeiro DRSV. Manejo do cuidado e a educação em saúde na atenção básica na pandemia do Coronavírus. J Nurs Health. 2020;10(4):20104020.,⁴⁵45. Rios AFM, Lira LSSP, Reis IM, Silva GA. Atenção Primária à Saúde frente à COVID-19: relato de experiência de um Centro de Saúde. Enferm Foco. 2020;11(1 Nº Espec):246-51. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3666
https://doi.org/10.21675/2357-707X.2020.... .

During the Covid-19 pandemic, the follow-up of patients with chronic non-communicable diseases (NCDs) was postponed and its number decreased worldwide, since the care of part of this cases was not urgent²¹21. Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, et al. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open. 2020;10(12):e043151. https://doi.org/10.1136/bmjopen-2020-043151
https://doi.org/10.1136/bmjopen-2020-043... ,²²22. Dias EG, Ribeiro DRSV. Manejo do cuidado e a educação em saúde na atenção básica na pandemia do Coronavírus. J Nurs Health. 2020;10(4):20104020.,²⁹29. Saint-Lary O, Gautier S, Le Breton J, Gilberg S, Frappé P, Schuers M, et al. How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey. BMJ Open. 2020;10(12):e042119. https://doi.org/10.1136/bmjopen-2020-042119
https://doi.org/10.1136/bmjopen-2020-042... ,³²32. Al Ghafri T, Al Ajmi F, Anwar H, Al Balushi L, Al Balushi Z, Al Fahdi F, et al. 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. https://doi.org/10.1177/2150132720967514
https://doi.org/10.1177/2150132720967514... ,³⁴34. Verhoeven V, Tsakitzidis G, Philips H, Van Royen P. Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs. BMJ Open. 2020;10(6):e039674. https://doi.org/10.1136/bmjopen-2020-039674
https://doi.org/10.1136/bmjopen-2020-039... ,⁴⁶46. Coma E, Mora E, Méndez L, Benítez M, Hermosilla E, Fàbregas M, et al. Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract. 2020;21:208 https://doi.org/10.1186/s12875-020-01278-8
https://doi.org/10.1186/s12875-020-01278... . In Muscat, Oman, all health units suspended face-to-face care of patients with NCDs at the beginning of the pandemic³²32. Al Ghafri T, Al Ajmi F, Anwar H, Al Balushi L, Al Balushi Z, Al Fahdi F, et al. 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. https://doi.org/10.1177/2150132720967514
https://doi.org/10.1177/2150132720967514... . In Spain and Belgium, although this suspension did not occur, the number of follow-ups of patients with diabetes mellitus and systemic arterial hypertension significantly decreased⁴⁶46. Coma E, Mora E, Méndez L, Benítez M, Hermosilla E, Fàbregas M, et al. Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract. 2020;21:208 https://doi.org/10.1186/s12875-020-01278-8
https://doi.org/10.1186/s12875-020-01278... ,⁴⁸48. Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, et al. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract. 2020;21:255. https://doi.org/10.1186/s12875-020-01326-3
https://doi.org/10.1186/s12875-020-01326... .

The administration of vaccines in children reduced in Spain⁴⁶46. Coma E, Mora E, Méndez L, Benítez M, Hermosilla E, Fàbregas M, et al. Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract. 2020;21:208 https://doi.org/10.1186/s12875-020-01278-8
https://doi.org/10.1186/s12875-020-01278... and outpatient services related to maternal and child health were discontinued in India⁴⁷47. Garg S, Basu S, Rustagi R, Borle A. Primary Health Care facility preparedness for outpatient service provision during the COVID-19 pandemic in India: cross-sectional study. JMIR Public Health Surveill. 2020;6(2):e19927. https://doi.org/10.2196/19927
https://doi.org/10.2196/19927... . France maintained outpatient care for other health problems while the Covid-19 care was directed and concentrated in specific centers¹⁶16. Prado NMBL, Rossi TRA, Chaves SCL, Barros SG, Magno L, Santos HLPC, et al. The international response of primary health care to COVID-19: document analysis in selected countries. Cad Saude Publica. 2020;36(12):e00183820. https://doi.org/10.1590/0102-311X00183820
https://doi.org/10.1590/0102-311X0018382... .

The postponement of the care of patients with NCDs, childcare, and the reduced vaccination coverage may have consequences that will extend after the Covid-19 pandemic, causing an overload in health systems²¹21. Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, et al. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open. 2020;10(12):e043151. https://doi.org/10.1136/bmjopen-2020-043151
https://doi.org/10.1136/bmjopen-2020-043... ,²⁹29. Saint-Lary O, Gautier S, Le Breton J, Gilberg S, Frappé P, Schuers M, et al. How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey. BMJ Open. 2020;10(12):e042119. https://doi.org/10.1136/bmjopen-2020-042119
https://doi.org/10.1136/bmjopen-2020-042... ,³⁴34. Verhoeven V, Tsakitzidis G, Philips H, Van Royen P. Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs. BMJ Open. 2020;10(6):e039674. https://doi.org/10.1136/bmjopen-2020-039674
https://doi.org/10.1136/bmjopen-2020-039... ,⁴⁶46. Coma E, Mora E, Méndez L, Benítez M, Hermosilla E, Fàbregas M, et al. Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract. 2020;21:208 https://doi.org/10.1186/s12875-020-01278-8
https://doi.org/10.1186/s12875-020-01278... . On the other hand, the reduced attendance of patients with NCDs to health units is probably related to the health authorities’ recommendations for people to stay at home and seek these services only if in case of Covid-19 symptoms²⁹29. Saint-Lary O, Gautier S, Le Breton J, Gilberg S, Frappé P, Schuers M, et al. How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey. BMJ Open. 2020;10(12):e042119. https://doi.org/10.1136/bmjopen-2020-042119
https://doi.org/10.1136/bmjopen-2020-042... .

Although health professionals working in PHC quickly organized themselves in response to the beginning of the pandemic, the targeting of Covid-19 care can cause health complications for a part of the population, whose care was postponed or suspended, and burden the health system.

Thus, the guarantee of comprehensive care during the pandemic became a major challenge for PHC, due to the valorization of care in hospital services and the detriment of other needs of the population⁵5. Alves MTG. Reflexões sobre o papel da Atenção Primária à Saúde na pandemia de COVID-19. Rev Bras Med Fam Comunidade. 2020;15(42):2496. https://doi.org/10.5712/rbmfc15(42)2496
https://doi.org/10.5712/rbmfc15(42)2496... ,²²22. Dias EG, Ribeiro DRSV. Manejo do cuidado e a educação em saúde na atenção básica na pandemia do Coronavírus. J Nurs Health. 2020;10(4):20104020.,⁴³43. Duarte RB, Medeiros LMF, Araújo MJAM, Cavalcante ASP, Souza EC, Alencar OM, et al. Agentes Comunitários de Saúde frente à COVID-19: vivências junto aos profissionais de enfermagem. Enferm Foco. 2020;11 (1 Nº Espec):252-6. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3597
https://doi.org/10.21675/2357-707X.2020.... ,⁴⁵45. Rios AFM, Lira LSSP, Reis IM, Silva GA. Atenção Primária à Saúde frente à COVID-19: relato de experiência de um Centro de Saúde. Enferm Foco. 2020;11(1 Nº Espec):246-51. https://doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3666
https://doi.org/10.21675/2357-707X.2020.... . Therefore, the pandemic reinforces the need to strengthen the role of PHC in the organization of health services in the SUS, as a way to optimize expenses and reduce hospitalizations, both for Covid-19 and other causes related to this level of care.

In Brazil, the Ministry of Health published guides and ordinances to guide PHC services and professionals. Moreover, state health departments, along with the Conselho Nacional de Secretários de Saúde (CONASS – National Council of Health Secretaries), supported municipal managers when discussing about restructuring services; however, despite of regulations, each municipality adapted itself according to its local reality and epidemiological, political, and financial issues.

PHC works as an organizer in the health network, which increases its importance in the fight against the Covid-19 pandemic, as it manages the early identification of suspected cases, the monitoring of mild cases, and the identification and referral of severe cases, besides contributing to reduce the burden of specialized and hospital services, which, consequently, reduces public spending.

This study presents an overview of how PHC services and professionals organized themselves to tackle the Covid-19 pandemic, addressing adjustments in infrastructure and care flows, such as establishing specific Covid-19 care units, separating infected and non-infected patients, using telemedicine as an alternative modality of care, and monitoring cases by applications and phone. However, gaps still exist in the literature, such as the evaluation of the effect of these actions and their effectiveness in mitigating the Covid-19 transmission, the analysis of the consequences for patients whose care was postponed or reduced (patients with NCDs, childcare follow-up, prenatal care, and vaccination coverage, for example) during the pandemic.

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