ABSTRACT

Health Surveillance strategies are crucial to organize a strong national response against the coronavirus disease 2019. In Brazil, it is necessary to think about the integration of the Primary Health Care (PHC) and local Health Surveillance. This review aims to analyze the normative documents produced by the Federal Government on this topic. Official documents published by the Federal Government were reviewed, finding 21 related. It was identified a greater support for implementation of intramural actions related to detection and notification of cases and contacts than for active search of community Covid-19 cases, local educational actions, community engagement, strengthening adherence to preventive measures, improvement of information sharing, or support of community’s social facilities. Little was produced about the articulation of PHC with local surveillance teams. Our findings reinforce what was found by other authors, who attested the insufficient importance attributed to PHC in Brazil, especially with regard to Health Surveillance actions. Unfortunately, our country has stood out for one of the worst managements of the health crisis in the world, and there is an urgent need to strengthen surveillance actions based on a strong, capillary, and community-based PHC.

KEYWORDS
Health Surveillance; Primary Health Care; Covid-19

Introduction

The 2019 coronavirus disease (Covid-19) pandemic is currently the biggest threat to the health of the world’s population, accounting for more than 130 million cases and nearly 3 million deaths worldwide by April 2021^{11 World Health Organization. WHO Coronavirus (Covid-19) Dashboard. Genebra: WHO; 2021. [acesso em 2021 abr 4]. Disponível em: https://covid19.who.int
https://covid19.who.int...} . Similar to what happened more than a hundred years ago, with the 1918 influenza pandemic, responsible for more than 50 million deaths, the planet faced again, at least until December 2020, a similar catastrophe without curative treatments or access to vaccines^{22 Johnson NPAS, Mueller J. Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza pandemic. Bull Hist Med. 2002 [acesso em 2021 abr 4]; 76(1):105-15. Disponível em: http://muse.jhu.edu/content/crossref/journals/bulletin_of_the_history_of_medicine/v076/76.1johnson.html
http://muse.jhu.edu/content/crossref/jou... ,33 Centers for Disease Control and Prevention. Information for Clinicians on Investigational Therapeutics for Patients with Covid-19. [local desconhecido]: CDC; 2021. [acesso em 2021 abr 4]. Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html
https://www.cdc.gov/coronavirus/2019-nco...} . Despite this, it is known that non-pharmacological measures reduce the spread of the virus and limit the occurrence of serious illness and death<sup>44 Bootsma MCJ, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in U.S. cities. Proc Natl Acad Sci U S A. 2007 [acesso em 2021 abr 4]; 104(18):7588-93. Disponível em: https://pubmed.ncbi.nlm.nih.gov/17416677/
https://pubmed.ncbi.nlm.nih.gov/17416677...

5 Ferguson NM, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce Covid-19 mortality and healthcare demand. Imp Coll Covid-19 Response Team. 2020. [acesso em 2021 abr 4]. Disponível em: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/
https://www.imperial.ac.uk/mrc-global-in... -66 Aquino EML, Silveira IH, Pescarini JM, et al. Social distancing measures to control the Covid-19 pandemic: Potential impacts and challenges in Brazil. Ciênc. Saúde Colet. 2020 [acesso em 2021 abr 4]; 25:2423-46. Disponível em: https://pubmed.ncbi.nlm.nih.gov/32520287/
https://pubmed.ncbi.nlm.nih.gov/32520287...</sup> . The international experience on such measures to combat infection by Sars-CoV-2 (coronavirus responsible for severe acute respiratory syndrome type-2) has shown how much unprecedented mobilization of health systems and national-level responses was needed<sup>77 World Health Organization. Strengthening the health system response to Covid-19 Recommendations for the WHO European Region Policy brief. Genebra: WHO; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/handle/10665/333072
https://apps.who.int/iris/handle/10665/3...

8 Jefferies S, French N, Gilkison C, et al. Covid-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Heal. 2020 [acesso em 2021 abr 4]; 5(11):e612-23. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S2468266720302255
https://linkinghub.elsevier.com/retrieve...

9 Benjamin GC. Ensuring health equity during the Covid-19 pandemic: the role of public health infrastructure. Rev Panam Salud Pública. 2020 [acesso em 2021 abr 4]; 1-4. Disponível em: https://iris.paho.org/handle/10665.2/52233
https://iris.paho.org/handle/10665.2/522... -1010 Cowling BJ, Ali ST, Ng TWY, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Heal. 2020 [acesso em 2021 abr 4]; 5(5):e279-88. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S2468266720300906
https://linkinghub.elsevier.com/retrieve...</sup> , recognizing the importance of decisive government leadership to implement surveillance interventions aimed at containing the transmission of this virus^{1111 World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (covid-19). Geneva: WHO; 2020. [acesso em 2021 abr 4]. Disponível em: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
https://www.who.int/docs/default-source/... ,1212 Nguyen TTP, Nguyen LH, Le HT, et al. Perceptions and Attitudes Toward covid-19-Related National Response Measures of Vietnamese: Implications for Pandemic Prevention and Control. Front Public Heal. 2020 [acesso em 2021 abr 4]; 8:1-9. Disponível em: https://pubmed.ncbi.nlm.nih.gov/33163473/
https://pubmed.ncbi.nlm.nih.gov/33163473...} . A major challenge is to implement these measures quickly, strategically and with effective engagement of the population, in a context of constant tension^{1313 World Health Organization. Regional Office for Europe. Strengthening the Health Systems Response to covid-19 Technical Guidance #1 Maintaining the delivery of essential health care services freeing up resources for the covid-19 response while mobilizing the health workforce for the covid-19 response. Genebra: WHO; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/handle/10665/332559
https://apps.who.int/iris/handle/10665/3...} .

The Brazilian Unified Health System (SUS), based on the principles of universality, integrality and equity, with the capillarity of its services, has the potential to deal with the pandemic^{1414 Associação Brasileira de Saúde Coletiva. Rede de Pesquisa em Atenção Primária à Saúde. Relatório: Desafios da APS no SUS no enfrentamento da Covid-19. Seminário Virtual da Rede APS da Abrasco. Rio de Janeiro: Abrasco; 2020.}. Public Health Surveillance (PHS) strategies allow the identification and monitoring of diseases, occurrences and health indicators of the population, and the production of agile and reliable information to support decision-making^{1515 Engstrom E, Melo E, Giovanella L, et al. Recomendações para a organização da Atenção Primária à Saúde no SUS no enfrentamento da Covid-19. Obs Covid-19 - FIOCRUZ. 2020 [acesso em 2021 abr 4]; 1-7. Disponível em: https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/recomendacoes_aps_no_sus_para_enfrentamento_da_covid-19_versao_leitura_uma_coluna_1_.pdf
https://portal.fiocruz.br/sites/portal.f...} . Therefore, in the context of the current pandemic, they are indispensable strategies to organize a strong national response^{1616 WHO Regional Office for Europe. Strengthening the health system response to Covid-19: Adapting primary health care services to more effectively address Covid-19. Technical working guidance #5. Copenhagen: WHO Regional Office for Europe; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/332783/WHO-EURO-2020-727-40462-54321-eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand...} . Efforts to expand and give greater precision to measures require organizing surveillance actions in health regions with Primary Health Care (PHC) as the organizing center and considering the different levels of complexity^{1616 WHO Regional Office for Europe. Strengthening the health system response to Covid-19: Adapting primary health care services to more effectively address Covid-19. Technical working guidance #5. Copenhagen: WHO Regional Office for Europe; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/332783/WHO-EURO-2020-727-40462-54321-eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand...} . The strengthening of the Brazilian PHC care model, characterized by a territorial and community approach, and with an important role in improving the population’s health conditions, can constitute one of the fundamental supports of the actions necessary to contain the problem^{1717 Sarti TD, Lazarini WS, Fontenelle LF, et al. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela Covid-19? Epidemiol e Serv saude Rev do Sist Unico Saude do Bras. 2020 [acesso em 2021 abr 4]; 29(2):1-5. Disponível em: https://www.scielo.br/j/ress/a/SYhPKcN7f8znKV9r93cpF7w/?format=pdf&lang=pt
https://www.scielo.br/j/ress/a/SYhPKcN7f...} . PHC teams know their population and territory well, which allows for a better analysis and interpretation of risks and vulnerabilities of individuals, families and the community^{1515 Engstrom E, Melo E, Giovanella L, et al. Recomendações para a organização da Atenção Primária à Saúde no SUS no enfrentamento da Covid-19. Obs Covid-19 - FIOCRUZ. 2020 [acesso em 2021 abr 4]; 1-7. Disponível em: https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/recomendacoes_aps_no_sus_para_enfrentamento_da_covid-19_versao_leitura_uma_coluna_1_.pdf
https://portal.fiocruz.br/sites/portal.f...} . In this way, PHC is essential in improving traditional surveillance actions through early and accurate detection of cases in the population for which they are responsible, tracing the contacts of identified cases, supervising patients in isolation, coordinating in close cooperation with the sectors of PHS of the municipality, mechanisms and flows of referral, counter-referral and matrix support, contributing, among other things, to a better understanding of the epidemiological evolution of the disease^{1414 Associação Brasileira de Saúde Coletiva. Rede de Pesquisa em Atenção Primária à Saúde. Relatório: Desafios da APS no SUS no enfrentamento da Covid-19. Seminário Virtual da Rede APS da Abrasco. Rio de Janeiro: Abrasco; 2020.,1616 WHO Regional Office for Europe. Strengthening the health system response to Covid-19: Adapting primary health care services to more effectively address Covid-19. Technical working guidance #5. Copenhagen: WHO Regional Office for Europe; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/332783/WHO-EURO-2020-727-40462-54321-eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... ,1818 Conselho Nacional de Saúde. Resolução no 588, de 12 de julho de 2018. Diário Oficial da União. Brasília, DF: CNS; 2018.}. Furthermore, actions such as articulation with the PHS of the municipalities to establish information flows, educational activities in the territory, awareness of the population, combating fake news or dissemination of measures to protect workers and users in the various social facilities can be actions developed in the scope of APS to combat the Covid-19 pandemic^{1919 Medina MG, Giovanella L, Bousquat A, et al. Atenção primária à saúde em tempos de Covid-19: o que fazer? Cad Saude Publica. 2020 [acesso em 2021 abr 4]; 36(8):1-5. Disponível em: http://cadernos.ensp.fiocruz.br/static/arquivo/CSP_1497_20_Atencao_pt.pdf
http://cadernos.ensp.fiocruz.br/static/a...} .

This review intends to identify the official documents produced by the Brazilian government to deal with Covid-19 related to the PHS that advocate interventions by PHC teams, and to analyze the proposed interventions in relation to the possibilities of action of PHC services in the SUS network, considered a one of the pillars of the response to emergency situations.

Material and methods

A review was carried out of the official documents published by the government of Brazil aimed at combating the Covid-19 pandemic within the scope of PHC. As inclusion criteria to compose this document review, we chose to select those publications available on the official websites of the Brazilian government. The authors consulted the documents available in the Coronavirus (Covid-19) tab on the official website of the Ministry of Health of Brazil (MS), the website of the ordinances published on Covid-19, which periodically organizes all documents produced by the federal government and published until December 31, 2020, and the Coronavirus tab of the Portal of the Secretariat for Primary Health Care. Another source was the website of the Deputy Chief for Legal Affairs of the General Secretariat of the Presidency of the Republic, which contains the Covid-19 Legislation. Additionally, searches were carried out on the website of the Official Gazette of the Federal Government, using the terms ‘Primary Care’ and ‘Covid-19’, limiting the search to those documents published until December 31, 2020 and excluding epidemiological bulletins and public calls. The title, summary and objective of the documents identified were read and analyzed in order to select those related to the topic addressed, that is, actions to combat the pandemic within the scope of PHC, and from them, those that involved PHS measures. In cases where the title and the syllabus or subject did not make the objective of the research clear or the document did not present an outline or subject, this data was sought by analyzing the complete document. Once the publications were collected, a duplicity check was carried out to remove the repeated documents. Those selected were read in full; and, still at this stage, some texts that did not correspond to the objectives of this research were excluded. In all, 3,274 official documents were located. After applying the inclusion and exclusion criteria, 386 documents were selected for reading. The detailed reading of the publications determined the need to deepen in 21 texts, which were read in their entirety, composing all the corpus of this research. The list of documents included in this analysis is presented in table 1.

The selected documents were analyzed in terms of the following aspects: ‘body that prepared the document’, ‘publication date’ and ‘type of intervention’. For the analysis of the type of intervention, as the main reference, the categories proposed by Medina et al.^{1919 Medina MG, Giovanella L, Bousquat A, et al. Atenção primária à saúde em tempos de Covid-19: o que fazer? Cad Saude Publica. 2020 [acesso em 2021 abr 4]; 36(8):1-5. Disponível em: http://cadernos.ensp.fiocruz.br/static/arquivo/CSP_1497_20_Atencao_pt.pdf
http://cadernos.ensp.fiocruz.br/static/a...} were adopted when analyzing the possibilities of action of PHC services in the SUS network that contribute to the control of the epidemic and that, simultaneously, fulfill their essential function of guaranteeing daily and capillary care, identifying that PHC performance can be systematized in four axes: i) PHS in the territories; ii) attention to users with Covid-19; iii) social support to vulnerable groups; and iv) continuity of APS’ actions. For this review, only official documents associated with the PHS in the territories axis were analyzed.

For this analysis, the PHS is understood, according to the theoretical model proposed by Silva and Vieira da Silva^{2020 Silva GAP, Vieira-da-Silva LM. Health surveillance: proposal for a tool to evaluate technological arrangements in local health systems. Cad. Saúde Publica. 2008 [acesso em 2021 abr 4]; 24(11):2463-75. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2008001100002&lang=pt%0Ahttp://www.scielo.br/pdf/csp/v24n11/02.pdf
http://www.scielo.br/scielo.php?script=s...} , as a process of organizing practices that articulate the promotion of the population’s health, prevention, risk control and the timely and adequate care of diseases. In this sense, Medina et al.^{1919 Medina MG, Giovanella L, Bousquat A, et al. Atenção primária à saúde em tempos de Covid-19: o que fazer? Cad Saude Publica. 2020 [acesso em 2021 abr 4]; 36(8):1-5. Disponível em: http://cadernos.ensp.fiocruz.br/static/arquivo/CSP_1497_20_Atencao_pt.pdf
http://cadernos.ensp.fiocruz.br/static/a...} propose that the PHS in the territories to face the epidemic implies the performance of interventions by the PHC teams that aim to block and reduce the risk of expansion, acting in an articulated way with the PHS of the municipalities, establishing flows of information to improve the quality of actions. Notification, detection, monitoring of cases, home isolation and quarantine of contacts are also central epidemic mitigation activities to be developed, as well as the encouragement of social isolation, that can be carried out by all team professionals, especially Community Health Agents (ACS), mobilizing local leaders and resources with wide dissemination of information and implementation of concrete measures. Other actions that may be developed by ACS are included, such as raising awareness among the population and combating stigma related to the disease, disseminating correct information on the prevention of Covid-19, combating fake news and supporting educational activities in the territory related to hygiene and protection of workers and users in the various social facilities, so that they constitute safe environments for the population.

Results and discussion

15 of the 21 selected documents were produced in March and June 2020; 11 documents were published during the administration of the former Minister of Health Luiz Henrique Mandetta; three during the administration of former Minister Nelson Teich and eight during the period of former Minister of Health General Eduardo Pazuello. As for the type, four corresponded to technical notes; five ordinances; one law; three recommendations, one with two versions; five protocols, one with four versions; a guide in two versions; a guideline; and the National Contingency Plan.

One of the first documents to be produced was the National Contingency Plan, on February 26, 2020, in a single version, followed by documents with specific objects, such as pharmaceutical assistance, recommendations for ACS, oral health strategy and general documents on individual preventive measures, safety at work and changes in the work process aimed at other PHC workers, among others. Ordinances were also published on financial incentives, reorganization of activities carried out within the scope of PHC, such as vaccination, consultation on the street, assistance to indigenous health and vulnerable populations. Subsequently, guides and guiding protocols for the prevention, control, surveillance, diagnosis and treatment of Covid-19 were published, being quickly updated in new versions, such as the case of the Protocol for the clinical management of Covid-19 in PHC, reaching the ninth version. The classification of official documents included in the analysis, according to the analysis categories adopted, is presented in table 2.

Public Health Surveillance

PHS actions within the scope of PHC are addressed in 21 documents. The National Plan, published in February 2020 (document 1), is the most comprehensive document on actions to combat the pandemic, but the ‘Epidemiological Surveillance Guide’, published in August 2020 (document 17), is the most specific document on surveillance strategies. In documents prior to this Guide, actions to strengthen surveillance emphasized the detection, notification and communication of cases, prioritizing epidemiological investigation, contact tracing and strengthening notification as part of surveillance actions in the PHC context (documents 1, 10, 12). However, there was a predominance of internal action, by specifying only the procedures for detection among people who seek the Family Health Units (USF) in person or by telephone, as well as the remote monitoring of patients treated for Influenza-like illness (ILI) (document 12). The most recent version of the ‘Epidemiological Surveillance Guide’ (document 17) incorporates the ‘clinical’, ‘clinical-epidemiological’ and ‘clinical-imaging’ criteria in the definition of a confirmed case, also including parameters such as olfactory or gustatory dysfunction, facilitating, somehow, the identification of cases in PHC contexts. It also reinforces that the notification becomes the responsibility of all services and health professionals who treat cases of ILI and Severe Acute Respiratory Syndrome (Sars). The PHC Units and Professionals also became reporting centers for all cases of ILI, Sars and asymptomatic cases through the e-SUS Notifica system, however considering that, as of December 2019, only 24% of PHC establishments are computerized^{2121 Brasil. Ministério da Saúde. Portal da Secretaria de Atenção Primária a Saúde. Municípios começam a receber custeio para informatização da APS. [Brasília, DF]: Ministério da Saúde; 2021.} and that, therefore, are limited to internet access and information technologies in the context of PHC, it is noteworthy that this document does not detail any additional support intended for PHC to perform these functions (document 17).

Regarding the investigation, tracing and monitoring of contacts, in the second version of the ‘Epidemiological Surveillance Guide’, it is clearly stated that, even in a poorly structured way, these are exclusive actions of the ‘investigator teams’ that would be composed of at least one technician from municipal health surveillance and another from primary care (document 17). It is evident that, even if the importance of surveillance of new suspected cases of ILI and contacts in the community is recognized, procedures are not detailed to make these actions possible, such as the coordination of PHS with municipal surveillance to encourage the functioning of these teams of investigators and to carry out the active search of the cases in a broad way. For the identification of intra-household contacts, nothing is mentioned about the approximation of the PHC teams with the municipal surveillance teams, minimizing the importance of exchanging information for the coordination of actions (documents 12 and 17).

Actions regarding the interaction between the PHC teams and the surveillance teams are only mentioned more clearly in document 17, but in a succinct way, highlighting that, during the care of all suspected patients, it is important to test the patient, notify the case and trigger surveillance to investigate the contacts. As for the ‘Consultation on the Streets’ teams, there is a special indication on the active search and continuity of care (document 6). The indication of isolation for people with respiratory symptoms and for their contacts residing at the same address was maintained exclusively by medical prescription, for a maximum of 14 days (document 5), without being clear the role of incentive mechanisms for isolation that could be adopted, incorporating the participation of other professionals from the health teams, or even from the surveillance teams.

Document 12 refers to the role of PHC teams in supporting active surveillance, but very succinctly, and on actions restricted to nursing homes/elderly homes, specifically on prevention, education on hygiene and distancing, and to reduce the risk of contagion (document 12). However, other documents suggested the possibility of APS acting in partnership with local surveillance teams in testing actions, guidance to the population on home isolation measures and preventive measures, remote monitoring of contacts and establishment of partnerships with residents’ associations, educational institutions and other bodies (documents 11, 13, 14, 17). These actions were specifically strengthened for the Psychosocial Care Network and to support strategic actions to support pregnancy, prenatal care and the puerperium, in documents that also incorporate a specific format for funding these actions (document 18 and 21). It will only be in September that two documents operationalized and allocated financial incentives to the actions of tracking and monitoring cases in a broad way, clearly establishing in their objectives to maintain and strengthen the integration of PHS and PHC, with a local perspective to identify in a timely manner the cases of Covid-19 and contacts, among other actions of PHS (documents 19 and 20).

The participation of ACS in specific surveillance actions is briefly suggested in the second version of the Surveillance Guide, as potential participants in the ‘investigator teams’ in charge of making home visits to monitor contacts (document 17). Even so, regarding the performance of this professional category, in previous documents, the home visit was recognized as a tool to inform and actively search for suspected cases and contacts of confirmed cases, in compliance with patient and professional safety measures (documents 7 and 9). Other surveillance actions that can be carried out by ACS were also detailed, such as: assisting the team in identifying suspected cases of ILI and Covid-19; assist the team in monitoring suspected and confirmed cases; carry out an active search for new suspected cases of ILI, indication of home isolation; advise the population about the disease, prevention measures and signs and symptoms (document 7 and 9).

In the documents evaluated, little was discussed about the flow of information between testing centers, laboratories, hospital centers and the municipal PHC network, and the sharing of information is carried out exclusively by the Laboratory Environment Manager (GAL) system for the Central Laboratories for Public Health (Lacen), and other laboratories would have to make the necessary adjustments regarding the use of the National Health Data Network (RNDS), making it difficult to exchange information and affecting the quality of surveillance actions (document 17). Likewise, no discussion was identified about the possibility of extensive testing within the scope of the PHC and the flows for transporting samples from the PHC network to the Lacen. It was only pointed out that this could be done through the use of rapid tests in symptomatic people with more than seven days of symptoms, prioritizing testing for risk groups, for which the intention of progressively providing more tests was mentioned (document 12).

Another aspect that was also mentioned, but briefly, was the importance of implementing actions that increase the population’s engagement with preventive measures such as social isolation, based on the mobilization of local leaders and resources in the various measures to combat Covid-19 (document 17). Only document 16 provides guidelines for action in social facilities, specifically on strengthening measures to prevent and control Sars-CoV-2 infections in Institutional Shelter Units for the elderly - Long-stay Institution for the Elderly (Ilpi). Likewise, little was mentioned about actions to disseminate correct information on the prevention of Covid-19, measures to support educational activities in the territory or measures to combat fake news, actions that could be carried out by ACS.

Final considerations

This review highlights that documentary production to combat the pandemic began before the diagnosis of the first confirmed case, still in January, when the Emergency Operations Center of the Ministry of Health — coordinated by the Health Surveillance Secretariat (SPHS/MS) — was implemented. This production was the majority between the months of March and June 2020, coinciding with the first wave of the pandemic; but only later, starting in August, with the second version of the Surveillance Guide, initiatives to articulate surveillance between the municipalities and the PHC health teams were clearly identified. During this period, the Ministry of Health underwent two ministerial changes, highlighting the inauguration of the last interim minister, a general with no experience in the field of health^{2222 Giovanella L, Medina MG, Aquino R, et al. Negacionismo, desdém e mortes: notas sobre a atuação criminosa do governo federal brasileiro no enfrentamento da Covid-19. Saúde debate. 2020 [acesso em 2021 abr 4]; 44(126):895-901. Disponível em: https://www.scielo.br/j/sdeb/a/yjzTqB9mNMpxj7hsrqmSmKs/?lang=pt
https://www.scielo.br/j/sdeb/a/yjzTqB9mN...} . Since December, the crisis has been worsening with a progressive increase in the incidence and mortality due to Covid-19^{11 World Health Organization. WHO Coronavirus (Covid-19) Dashboard. Genebra: WHO; 2021. [acesso em 2021 abr 4]. Disponível em: https://covid19.who.int
https://covid19.who.int... ,2323 Stein C, Cousin E, Machado ÍE, et al. A pandemia da Covid-19 no Brasil: a série de projeções do Institute for Health Metrics and Evaluation e a evolução observada, maio a agosto de 2020. Epidemiol Serv Saúde. 2021 [acesso em 2021 abr 4]; 30(1):e2020680. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2237-96222021000100308&tlng=pt
http://www.scielo.br/scielo.php?script=s...} , in contrast to a scarce production of official documents on the subject. Regarding the reorganization of PHC services to face the pandemic, the limited technical normative production of the federal government attests to the low priority, making it difficult to implement effective measures to combat the pandemic. This production placed greater emphasis on case detection and notification strategies, relegating crucial aspects such as guidelines for technical support to the teams, dissemination of correct information on prevention, combating fake news, public awareness or the establishment of information flows with other points in the network.

International experience has shown how essential the coordination of actions at the national level is for a successful management of the health crisis^{77 World Health Organization. Strengthening the health system response to Covid-19 Recommendations for the WHO European Region Policy brief. Genebra: WHO; 2020. [acesso em 2021 abr 4]. Disponível em: https://apps.who.int/iris/handle/10665/333072
https://apps.who.int/iris/handle/10665/3... ,88 Jefferies S, French N, Gilkison C, et al. Covid-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Heal. 2020 [acesso em 2021 abr 4]; 5(11):e612-23. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S2468266720302255
https://linkinghub.elsevier.com/retrieve...} . However, in the case of Brazil, the government has contributed to the lack of coordination and inefficiency of the national response^{2222 Giovanella L, Medina MG, Aquino R, et al. Negacionismo, desdém e mortes: notas sobre a atuação criminosa do governo federal brasileiro no enfrentamento da Covid-19. Saúde debate. 2020 [acesso em 2021 abr 4]; 44(126):895-901. Disponível em: https://www.scielo.br/j/sdeb/a/yjzTqB9mNMpxj7hsrqmSmKs/?lang=pt
https://www.scielo.br/j/sdeb/a/yjzTqB9mN...} , when the most important thing would be to guarantee the technical and operational support necessary for the development and implementation of measures to contain the transmission of the disease^{2424 Teixeira MG, Medina MG, Costa MCN, et al. Reorganização da atenção primária à saúde para vigilância universal e contenção da Covid-19. Epidemiol Serv Saúde. 2020 [acesso em 2021 abr 4]; 29(4):e2020494. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/32756829
http://www.ncbi.nlm.nih.gov/pubmed/32756...} . One of the crucial mechanisms for combating any epidemic is the establishment of PHS strategies^{2424 Teixeira MG, Medina MG, Costa MCN, et al. Reorganização da atenção primária à saúde para vigilância universal e contenção da Covid-19. Epidemiol Serv Saúde. 2020 [acesso em 2021 abr 4]; 29(4):e2020494. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/32756829
http://www.ncbi.nlm.nih.gov/pubmed/32756...} , in order to structure a rapid, comprehensive response that allows the entire population to be made aware of preventive measures. In this context, the articulation between surveillance and PHC appears as a key issue^{2424 Teixeira MG, Medina MG, Costa MCN, et al. Reorganização da atenção primária à saúde para vigilância universal e contenção da Covid-19. Epidemiol Serv Saúde. 2020 [acesso em 2021 abr 4]; 29(4):e2020494. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/32756829
http://www.ncbi.nlm.nih.gov/pubmed/32756...} . However, the Brazilian PHC has been suffering serious threats and dangerous setbacks, which are decharacterizing it, approaching it to a model of individual assistance, which responds only to acute problems, without link, continuity, coordination or population responsibility^{2222 Giovanella L, Medina MG, Aquino R, et al. Negacionismo, desdém e mortes: notas sobre a atuação criminosa do governo federal brasileiro no enfrentamento da Covid-19. Saúde debate. 2020 [acesso em 2021 abr 4]; 44(126):895-901. Disponível em: https://www.scielo.br/j/sdeb/a/yjzTqB9mNMpxj7hsrqmSmKs/?lang=pt
https://www.scielo.br/j/sdeb/a/yjzTqB9mN... ,2525 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Ciênc. Saúde Colet. 2020 [acesso em 2021 abr 4]; 25(4):1475-82. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232020000401475&tlng=pt
http://www.scielo.br/scielo.php?script=s...} . Faced with a limited response from the federal government, Brazilian states and municipalities have been faced with the challenge of regulating, inspecting, carrying out the necessary surveillance and providing health care^{2626 Fleury S. O Vírus, os Parasitas e os Vampiros: Covid-19, desmonte do SUS e a EC 95. Centro Brasileiro de Estudos de Saúde. 2020. [acesso em 2021 abr 4]. Disponível em: http://cebes.org.br/2020/03/o-virus-os-parasitas-e-os-vampiros-covid-19-desmonte-do-sus-e-a-ec-95/
http://cebes.org.br/2020/03/o-virus-os-p...} .

Currently, there is a second pandemic wave in full expansion, and it is more than urgent to expand PHS actions, especially the capacity to detect and trace contacts, imperative to contain the expansion of Covid-19, as has it been amply demonstrated by the international experience, emphasizing that the PHC is the privileged place of the health system to coordinate this type of action^{1515 Engstrom E, Melo E, Giovanella L, et al. Recomendações para a organização da Atenção Primária à Saúde no SUS no enfrentamento da Covid-19. Obs Covid-19 - FIOCRUZ. 2020 [acesso em 2021 abr 4]; 1-7. Disponível em: https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/recomendacoes_aps_no_sus_para_enfrentamento_da_covid-19_versao_leitura_uma_coluna_1_.pdf
https://portal.fiocruz.br/sites/portal.f... ,1919 Medina MG, Giovanella L, Bousquat A, et al. Atenção primária à saúde em tempos de Covid-19: o que fazer? Cad Saude Publica. 2020 [acesso em 2021 abr 4]; 36(8):1-5. Disponível em: http://cadernos.ensp.fiocruz.br/static/arquivo/CSP_1497_20_Atencao_pt.pdf
http://cadernos.ensp.fiocruz.br/static/a... ,2727 Cassone A, Crisanti A. Can reasoned mass testing impact covid-19 outcomes in wide community contexts?An evidence-based opinion: Mass testing and outcomes of Covid-19 in Lombardy and Veneto. Pathog Glob Health. 2021 [acesso em 2021 abr 4]; 115(3):203-207. Disponível em: https://pubmed.ncbi.nlm.nih.gov/33686907/
https://pubmed.ncbi.nlm.nih.gov/33686907... ,2828 Raffle AE, Pollock AM, Harding-Edgar L. Covid-19 mass testing programmes. BMJ. 2020 [acesso em 2021 abr 4]; 370:m3262. Disponível em: https://www.bmj.com/lookup/doi/10.1136/bmj.m3262
https://www.bmj.com/lookup/doi/10.1136/b...} .

The analysis presented in this article, despite its possible limitations, such as being based exclusively on documentation produced by the federal government, corroborates what has been warned by several authors who attest to the insufficient importance that has been attributed to PHC in the country, in the management and implementation of actions to control the pandemic, especially regarding PHS^{1717 Sarti TD, Lazarini WS, Fontenelle LF, et al. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela Covid-19? Epidemiol e Serv saude Rev do Sist Unico Saude do Bras. 2020 [acesso em 2021 abr 4]; 29(2):1-5. Disponível em: https://www.scielo.br/j/ress/a/SYhPKcN7f8znKV9r93cpF7w/?format=pdf&lang=pt
https://www.scielo.br/j/ress/a/SYhPKcN7f... ,2222 Giovanella L, Medina MG, Aquino R, et al. Negacionismo, desdém e mortes: notas sobre a atuação criminosa do governo federal brasileiro no enfrentamento da Covid-19. Saúde debate. 2020 [acesso em 2021 abr 4]; 44(126):895-901. Disponível em: https://www.scielo.br/j/sdeb/a/yjzTqB9mNMpxj7hsrqmSmKs/?lang=pt
https://www.scielo.br/j/sdeb/a/yjzTqB9mN... ,2424 Teixeira MG, Medina MG, Costa MCN, et al. Reorganização da atenção primária à saúde para vigilância universal e contenção da Covid-19. Epidemiol Serv Saúde. 2020 [acesso em 2021 abr 4]; 29(4):e2020494. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/32756829
http://www.ncbi.nlm.nih.gov/pubmed/32756... ,2929 Vitória ÂM, Campos GWS. Só com APS forte o sistema pode ser capaz de achatar a curva de crescimento da pandemia e garantir suficiência de leitos UTI. São Paulo: Cosemssp; 2020. [acesso em 2021 abr 4]. Disponível em: http://www.cosemssp.org.br/wp-content/uploads/2020/04/So-APS-forte-para-ter-leitos-UTI-.pdf
http://www.cosemssp.org.br/wp-content/up... ,3030 Nedel FB. Enfrentando a Covid-19: APS forte agora mais que nunca! APS EM Rev. 2020 [acesso em 2021 abr 4]; 2(1):11-6. Disponível em: https://apsemrevista.org/aps/article/view/68
https://apsemrevista.org/aps/article/vie...} . These findings reinforce the argument that, unfortunately, Brazil has been highlighted as one of the worst managements of the health crisis in the world.

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