0343/2024 - Diferenças regionais na reorganização da Atenção Primária à Saúde no contexto da pandemia de Covid-19 no Brasil
Regional differences in the reorganization of Primary Health Care in the context of the Covid-19 pandemic in Brazil
Autor:
• Ana Paula de Vechi Corrêa - Corrêa, A.P.V. - <paulavechi@yahoo.com.br>ORCID: https://orcid.org/0000-0002-9098-3594
Coautor(es):
• Gustavo Diego Magno - Magno, G.D - <gusmagno@gmail.com>ORCID: https://orcid.org/0000-0003-3656-9170
• Rafaela Carla Piotto Rodrigues - Rodrigues, R.C.P - <rafapiotto@yahoo.com.br>
ORCID: https://orcid.org/0000-0001-8587-3115
• Rodrigo das Neves Cano - Cano, R.N - <rodrigo.neves@unesp.br>
ORCID: https://orcid.org/0009-0002-5570-8279
• Isabel MarÃa López Medina - Medina, I.M.L - <imlopez@ujaen.es>
ORCID: https://orcid.org/0000-0002-3437-9229
• Carmen Alvarez Nieto - Nieto, C.A - <calvarez@ujaen.es>
ORCID: https://orcid.org/0000-0002-0913-7893
• SÃlvia Carla da Silva André Uehara - Uehara, S.C.S.A - <silviacarla@ufscar.br>
ORCID: https://orcid.org/0000-0002-0236-5025
Resumo:
Estudo transversal analÃtico, realizado com 1134 gestores da APS dos municÃpios brasileiros, que objetivou analisar e comparar a reorganização da assistência oferecida pela Atenção Primária à Saúde (APS) nas diferentes regiões brasileiras, durante a fase crÃtica da pandemia de Covid-19. Os dados foram coletados por questionário autorrespondido no Google Forms, entre setembro de 2021 e setembro de 2022. O modelo de regressão de Poisson com efeito aleatório foi utilizado para estimar as razões de prevalência e adotou-se nÃvel de significância de 5%. A readequação de estrutura fÃsica para o atendimento de Covid-19 foi 15% (IC: 0,76; 0,96) menor no Sudeste e 19% (IC: 0,69; 0,94) menor no Nordeste do que no Sul. O teleatendimento foi 23% (IC: 0,62; 0,96) menor no Norte do que no Sudeste e 25% (0,6; 0,95) menor no Norte do que Sul. Na região Nordeste, o encaminhamento de usuários com risco de agravamento da Covid-19 apresentou-se 6% (IC: 1; 1,13 e 1,02; 1,09) maior que as regiões Norte e Sul. Evidenciou-se que todas as regiões adotaram medidas para reorganizar a APS frente a pandemia, entretanto, de maneiras distintas, apontando a necessidade de uma abordagem mais abrangente e equitativa na gestão da saúde, especialmente em emergências sanitárias.Palavras-chave:
Atenção Primária à Saúde; Covid-19; Iniquidades em saúde; Gestão em Saúde; Tecnologias da Informação e Comunicação.Abstract:
The objective of this study was to analyze and compare the reorganization of assistance offered by Primary Health Care (PHC) in different Brazilian regions, during the critical phase of the Covid-19 pandemic. This is an analytical cross-sectional study, carried out with PHC managers in Brazilian municipalities. Data were collected through a self-answered questionnaire on Google Forms, between April and September 2022 and were analyzed using prevalence ratios, using a Poisson regression model with a random effect; a significance level of 5% was adopted. The readjustment of physical structure for Covid-19 care was 15% (CI: 0.76; 0.96) lower in the Southeast and 19% (CI: 0.69; 0.94) lower in the Northeast than in the South. Telecare was 23% (CI: 0.62; 0.96) lower in the North than in the Southeast and 25% (0.6; 0.95) lower in the North than in the South. In the Northeast region, the referral of users at risk of worsening Covid-19 was 6% (CI: 1; 1.13 and 1.02; 1.09) higher than in the North and South regions. It was evident that all regions adopted measures to reorganize PHC in response to the pandemic, however, in different ways, highlighting the need for a more comprehensive and equitable approach to health management, especially in health emergencies.Keywords:
Primary Health Care; COVID-19; Health Inequities; Health Management; Information TechnologyConteúdo:
Acessar Revista no ScieloOutros idiomas:
Regional differences in the reorganization of Primary Health Care in the context of the Covid-19 pandemic in Brazil
Resumo (abstract):
The objective of this study was to analyze and compare the reorganization of assistance offered by Primary Health Care (PHC) in different Brazilian regions, during the critical phase of the Covid-19 pandemic. This is an analytical cross-sectional study, carried out with PHC managers in Brazilian municipalities. Data were collected through a self-answered questionnaire on Google Forms, between April and September 2022 and were analyzed using prevalence ratios, using a Poisson regression model with a random effect; a significance level of 5% was adopted. The readjustment of physical structure for Covid-19 care was 15% (CI: 0.76; 0.96) lower in the Southeast and 19% (CI: 0.69; 0.94) lower in the Northeast than in the South. Telecare was 23% (CI: 0.62; 0.96) lower in the North than in the Southeast and 25% (0.6; 0.95) lower in the North than in the South. In the Northeast region, the referral of users at risk of worsening Covid-19 was 6% (CI: 1; 1.13 and 1.02; 1.09) higher than in the North and South regions. It was evident that all regions adopted measures to reorganize PHC in response to the pandemic, however, in different ways, highlighting the need for a more comprehensive and equitable approach to health management, especially in health emergencies.Palavras-chave (keywords):
Primary Health Care; COVID-19; Health Inequities; Health Management; Information TechnologyLer versão inglês (english version)
Conteúdo (article):
Diferenças regionais na reorganização da Atenção Primária à Saúde no contexto da pandemia de Covid-19 no Brasil.Regional differences in the reorganization of primary health care in the context of the COVID-19 pandemic in Brazil.
Ana Paula de Vechi Corrêa - Corrêa, A.P.V. -
ORCID: https://orcid.org/0000-0002-9098-3594
• Gustavo Diego Magno - Magno, G.D -
ORCID: https://orcid.org/0000-0003-3656-9170
• Rafaela Carla Piotto Rodrigues - Rodrigues, R.C.P -
ORCID: https://orcid.org/0000-0001-8587-3115
• Rodrigo das Neves Cano - Cano, R.N -
ORCID: https://orcid.org/0009-0002-5570-8279
• Isabel MarÃa López Medina - Medina, I.M.L -
ORCID: https://orcid.org/0000-0002-3437-9229
• Carmen Alvarez Nieto - Nieto, C.A -
ORCID: https://orcid.org/0000-0002-0913-7893
• SÃlvia Carla da Silva André Uehara - Uehara, S.C.S.A -
ORCID: https://orcid.org/0000-0002-0236-5025
RESUMO
Estudo transversal analÃtico, realizado com 1134 gestores da APS dos municÃpios brasileiros, que objetivou analisar e comparar a reorganização da assistência oferecida pela Atenção Primária à Saúde (APS) nas diferentes regiões brasileiras, durante a fase crÃtica da pandemia de Covid-19. Os dados foram coletados por questionário autorrespondido no Google Forms, entre setembro de 2021 e setembro de 2022. O modelo de regressão de Poisson com efeito aleatório foi utilizado para estimar as razões de prevalência e adotou-se nÃvel de significância de 5%. A readequação de estrutura fÃsica para o atendimento de Covid-19 foi 15% (IC: 0,76; 0,96) menor no Sudeste e 19% (IC: 0,69; 0,94) menor no Nordeste do que no Sul. O teleatendimento foi 23% (IC: 0,62; 0,96) menor no Norte do que no Sudeste e 25% (0,6; 0,95) menor no Norte do que Sul. Na região Nordeste, o encaminhamento de usuários com risco de agravamento da Covid-19 apresentou-se 6% (IC: 1; 1,13 e 1,02; 1,09) maior que as regiões Norte e Sul. Evidenciou-se que todas as regiões adotaram medidas para reorganizar a APS frente a pandemia, entretanto, de maneiras distintas, apontando a necessidade de uma abordagem mais abrangente e equitativa na gestão da saúde, especialmente em emergências sanitárias.
Palavras-chave: Atenção Primária à Saúde; Covid-19; Iniquidades em saúde; Gestão em Saúde; Tecnologias da Informação e Comunicação.
ABSTRACT
The aim of this study was to compare the reorganization of primary health care (PHC) across the different regions of Brazil during the critical phase of the COVID-19 pandemic. We conducted an analytical cross-sectional study with municipal primary care managers. The data were collected between September 2021 and September 2022 using a self-administered questionnaire created in Google Forms. The data were analyzed by means of prevalence ratios calculated using Poisson regression with random effects, adopting a 5% significance level. Prevalence of modifications to the physical structure of health facilities to care for suspected and confirmed COVID-19 cases was 15% (CI: 0.76; 0.96) and 19% (CI: 0.69; 0.94) lower in the Southeast and Northeast, respectively, than in the South. Prevalence of teleconsultation was 23% (CI: 0.62; 0.96) lower in the North than in the Southeast and 25% (0.6; 0.95) lower in the North than in the South. Referral of COVID-19 patients at risk of clinical deterioration was 6% (CI: 1; 1.13 and 1.02; 1.09) higher in the Northeast than in the North and South. The findings show that while all regions adopted measures to reorganize PHC to respond to the pandemic, these measures were implemented differently across regions, underlining the need for a more comprehensive and equitable approach to health management, especially during health emergencies.
Keywords: Primary Health Care; COVID-19; Health Inequities; Health Management; Information Technology.
INTRODUCTION
The COVID-19 pandemic represents a global challenge, placing significant pressure on health systems around the world1. Primary health care (PHC) has played an essential role in the response to this major health crisis. In this respect, it is worth highlighting that PHC is considered the gateway to the health care network and first point of contact between patients and the health system. PHC plays a central role in the prevention, early detection, treatment and management of disease2, and was pivotal in controlling the COVID-19 pandemic and mitigating its health impacts3.
Adaptation of PHC to meet the challenges posed by the COVID-19 pandemic has differed across health systems, with each country adopting its own protective measures and protocols to deal with the health emergency4,5. However, growing financial pressure, equipment and supplies shortages, health worker layoffs and hospital bed shortages, particularly in intensive care units (ICUs), have challenged health systems around the world6. Countries with more PHC-orientated public health systems have therefore been more effective in responding to the pandemic7.
In Brazil, states and municipalities have responded differently to the sudden changes in health demands in a quest to rapidly reorganize services in order to avoid health system collapse8. The health emergency sparked by COVID-19 was marked by a lack of national coordination. Against the backdrop of a decentralized health system and lack of national coordination, promoting cooperation between different levels of management has become a major challenge, requiring state health managers to guide municipal level responses in order to guarantee the efficiency and effectiveness of the measures adopted. This collaboration has become imperative to ensure adequate provision of supplies, personal protective equipment, staff, training and COVID-19 vaccines9-11.
An analysis of COVID-19 contingency plans drawn up by state governments in Brazil shows that the way in which PHC services were organized and restructured to respond to the pandemic had a direct impact on disease morbidity and mortality, especially during the public health emergency. It is important to emphasize that the adoption of science-based health surveillance actions prevented the resurgence of the disease (i.e. new peaks), especially in states where strategies were implemented to boost PHC services, focusing on early detection, immediate notification, constant surveillance of positive cases and recording of case outcomes12.
One of the strategies adopted by PHC services around the world after the onset of the pandemic was telemedicine, including the development of apps and video or teleconsultations, facilitating consultation at a distance and compliance with social isolation measures. Electronic prescriptions have also been used in several countries, such as Albania, Austria, the Czech Republic, Macedonia and Lithuania13. In addition to telemedicine, doctors in France, Italy and Belgium also dispensed medical prescriptions remotely13-15.
In Australia, besides telemedicine, health professionals received online training and information on protective measures was disseminated to more distant communities16. Primary health care centers in Greece, Iceland and Spain performed COVID-19 screening tests in specific locations to prevent contact between patients with suspected COVID-19 and other patients. In the Netherlands and Iceland, primary care services created different opening hours for patients with COVID-19 symptoms11.
Countries have adopted distinctive and at the same time similar strategies and actions in the context of PHC as part of their COVID-19 response, especially in the early stages of the pandemic. These include telemedicine consultations, where the patient receives necessary support without the risk of infection, and remote psychological support to help patients cope with fear and grief.
However, studies have not addressed the reorganization of PHC during the health emergency in a country of continental proportions like Brazil. This study therefore seeks to address this knowledge gap by comparing the reorganization of PHC services across the different regions of Brazil during the most critical phase of the COVID-19 pandemic.
METHOD
We conducted an analytical cross-sectional study of PHC services in Brazil. The target population was municipal primary care managers in municipalities with at least one confirmed case of COVID-19 in 2020 and 2021, considered the most critical period of the pandemic. Sample size was calculated based on one manager per municipality, adopting a relative error of 5.82%, prevalence of 50% and 95% confidence interval, resulting in 1,134 participants.
The following inclusion criteria were established: participants who reported being a municipal primary care manager for at least three months during the COVID-19 pandemic. Managers who were on leave and/or holiday during the pandemic were excluded.
The data were collected between September 2021 and September 2022 using a self-administered questionnaire created in Google Forms. The questionnaire was designed based on the Ministry of Health\'s Protocol for the Clinical Management of COVID-19 in Primary Health Care Services17 and covered the following variables: identification of suspected cases of influenza and COVID-19; infection prevention in health facilities; influenza severity stratification; therapeutic management and home isolation of COVID-19 patients with mild symptoms; early diagnosis and referral of severe cases to urgent/emergency services or hospitals; immediate notification; clinical monitoring; community prevention measures and active surveillance support.
To reach the target population, the survey was publicized through the National Council of Health Secretaries (CONASS) and National Council of Municipal Health Secretaries (CONASEMS), which forwarded the questionnaire to the municipal health departments stressing the importance of their participation in the study. State council of municipal health secretaries (COSEMS) supporters also collaborated in publicizing the survey in regional health departments.
The data were described using absolute frequencies and percentages (qualitative variables) and means, standard deviation and minimum, medium and maximum (quantitative variables).
Poisson regression with random effects18 was used to estimate prevalence ratios to compare regions. All analyses were performed using SAS 9.4, adopting a 5% significance level. The study was approved by the Federal University of São Carlos’ research ethics committee (reference code CAAE 52527521.8.0000.5504).
RESULTS
A total of 1134 managers from municipalities across all regions of Brazil took part in the study: 40.4% (458) from the Southeast, 27.9% (316) from the Northeast, 18.6% (211) from the South, 8.5% (97) from the North and 4.6% (52) from the Midwest.
The comparisons between the Midwest, North and South showed that all participants reported that: PHC services had been adapted to respond to the COVID-19 pandemic; modifications to the physical structure of health facilities had been made; COVID-19 protocols had been implemented; health professionals received training in the care and management of suspected COVID-19 cases/diagnosis; staff in high risk groups were relocated to work from home; suspected COVID-19 cases were notified within 24 hours; patients at risk of clinical deterioration were referred; and teleconsultations were implemented. However, none of the results were statistically significant (Table 1).
Telemonitoring of at risk patients every 24 hours and patients with flu-like symptoms every 48 hours was 19% (CI: 1.02; 1.39) and 21% (CI: 1.02; 1.44) more prevalent in the Midwest than in the North (Table 1).
In the comparisons between the Midwest and Southeast, no statistically significant differences were found between the regions for adaptation of PHC services to respond to the COVID-19 pandemic, implementation of COVID-19 protocols, health care staff training in case management, relocation of staff in high risk groups to home working, notification of suspected COVID-19 cases within 24 hours, use of teleconsultations and telemonitoring of at risk patients every 24 hours and patients with flu-like symptoms every 48 hours. However, all participants reported having implemented these measures (Table 1).
Prevalence of modifications to the physical structure of health facilities to care for suspected and confirmed COVID-19 cases was 15% (CI: 0.76; 0.96) lower in the Southeast than in the South, while referral of COVID-19 patients at risk of clinical deterioration was 4% (CI: 1; 1.08) more prevalent in the Southeast than in the South (Table 1).
Table 1
The comparisons between the Northeast, North, Southeast and South show that modifications to the physical structure of PHC services to treat suspected and confirmed COVID-19 cases was 19% (CI: 0.69; 0.94) less prevalent in the Northeast than the South. Relocation of health workers at risk of developing the severe form of COVID-19 to home working was 8% (CI: 1.03; 1.14) more prevalent in the Northeast than in the Southeast and 7% (CI: 1; 1.14) more prevalent in the Northeast than in the South (Table 2).
Referral of COVID-19 patients at risk of clinical deterioration to other points in the health system was more prevalent in the Northeast than in the other regions: 6% (CI: 1; 1.13 and 1.02; 1.09) more prevalent than in the North and South; and 2% (CI: 1; 1.03) more prevalent than in the Southeast (Table 2).
No statistically significant differences were found between the North, Southeast and South for the variables adaptation of PHC services to respond to the COVID-19 pandemic, modifications to the physical structure of PHC facilities, implementation of COVID-19 protocols, health worker training, relocation of health workers in high risk groups to home working, early notification of cases, referral of COVID-19 patients at risk of clinical deterioration to other points in the health system, telephone monitoring of at risk patients every 24 hours and telephone monitoring of patients with flu-like symptoms every 48 hours. However, all participants in these regions reported that they had adopted these measures (Table 2).
Prevalence of the use of information technology for pre-clinical consultations, diagnosis, patient monitoring and consultations was 23% (CI: 0.62; 0.96) lower in the North region than in the Southeast and 25% (0.6; 0.95) lower in the North than in the South (Table 2).
Table 2
DISCUSSION
Reorganization of PHC services to respond to the COVID-19 health emergency was undertaken across all the municipalities analyzed in this study, although to a varying degree and with differing focus, according to the availability of equipment and services in the local health system. While some regions made more progress in the use of health information and communications technology (ICT), others made more advances with modifications to the physical structure of health facilities.
The findings show that the region that did the most to adapt PHC services during the critical phase of the pandemic was the South. This may reflect the specific logistical and management challenges faced by each region in adapting health facilities to deal with the additional demand generated by the pandemic. In addition, it is important to note that services in the South may have required only limited adaptation given the greater number of primary care centers with adequate infrastructure and facilities before the onset of the pandemic.
In this respect, a study with a sample of 5,543 municipalities conducted before the pandemic reported that the South and Midwest had the best overall primary care center infrastructure and facilities, while the North had the worst19. The findings also showed that per capita municipal and federal government spending on PHC is higher and lower, respectively, in municipalities with smaller populations. Thus, more populous regions with large urban agglomerations depend more on federal funding to adapt PHC services, while less populous municipalities depend more on their own resources to adapt to their specific needs, with the South having better PHC infrastructure and facilities prior to the pandemic.
Our finding showing that services in the Northeast made less modifications to the physical structure of health facilities than those in the South may also be explained by differences in the adoption of local health policies that influence the prioritization of investment in health infrastructure and care and prevention. A study conducted before the pandemic found that the South and Southeast spent more on health per capita, had more hospital beds, made more hospital admissions and carried out more per capita outpatient appointments than other regions20.
It was also found that regions with higher HDI had more public health resources, while regions with lower HDI, especially the North and Northeast, had greater FHS coverage20. Thus, given its limited resources compared to the South, the North may have prioritized investment in the Family Health Strategy (FHS) for direct actions to tackle COVID-19, such as contact tracing and monitoring of suspected and confirmed cases by primary care workers, especially community health workers21. In addition, evidence shows that FHS coverage is associated with lower COVID-19 mortality rates due to the work of family health teams and community health workers in healthcare facility catchment areas, including home visits and contact tracing, especially in socially vulnerable areas22.
Our findings also show that prevalence of referral of COVID-19 patients at risk of clinical deterioration to other points in the health system was higher in the Northeast. This may be explained by higher FHS coverage in this region, meaning that more health teams and professionals carry out patient monitoring in FHS catchment areas. Health care center professionals should monitor suspected and confirmed COVID-19 cases and refer people at risk of clinical deterioration to another level of care according to bed availability in the health system17. Rigorous monitoring and team training were essential for ensuring timely necessary referral, especially considering that unnecessary referral can overburden other levels of care, limiting health system effectiveness23.
The findings of the current study also reveal significant regional differences in telemonitoring of at risk patients and those with flu-like symptoms, with prevalence being higher in the Midwest than in the North. These findings are corroborated by a previous study on the use of ICT in health care facilities in Brazil during the pandemic also showing that prevalence of remote patient monitoring in facilities with internet access was higher in the Midwest than in the North24.
Our findings also show that prevalence of ICT use for teleconsultation was lower in the North than in Northeast. The study mentioned above showed that prevalence of teleconsultation was higher in the Northeast and Midwest than in the North24. Furthermore, prevalence of relocation of workers in high risk groups to home working was highest in the Northeast. Working at home can be an effective strategy for protecting workers and ensuring the continuity of health services during the pandemic using ICT.
Although prevalence of the use of ICT was lower in the North than in the Northeast, access to computers and the internet and use of electronic medical records in health facilities was greater in the North than in the Northeast24. It is worth noting that before the pandemic ICT use was highest in the South and lowest in the North region, due to infrastructure and connectivity issues. These findings therefore highlight the need for investment to improve internet infrastructure and access and ensure adequate provision of electronic devices and software in order to optimize primary health care, especially in the North and Northeast25.
The use of ICT for remote consultation helps foster a preventive approach, patient monitoring, case discussion with professionals from other regions and timely necessary interventions, as well as providing faster access to diagnosis and treatment26. Remote consultation during the critical period of the pandemic helped patients avoid travel and unnecessary social contact, enabling services to refer suspected and confirmed COVID-19 cases to telemedicine services27 and provide health care to patients living far away who have difficulty getting to and from health facilities28. Nevertheless, evidence suggests that ICT will continue to be used by PHC services to complement other consolidated strategies29,30.
The findings of this study underline the importance of investing in infrastructure and ICT to strengthen the response capacity of PHC services in less developed regions of the country and ensure equitable access to health services under both normal circumstances and during health emergencies. However, our findings also show that regions with poorer access to computers and the internet made greater use of remote monitoring and teleconsultation than other regions with better access. This suggests that non-use of ICT is also linked to local management decision-making, thus emphasizing the importance of training for both managers and health professionals.
PHC plays a vital role in the context of a pandemic, being the front door to the health system and having the capacity to detect and monitor COVID-19 cases. To this end, there is a need for effective coordination between disease surveillance and PHC at municipal level to ensure early identification of cases and establish measures to contain the spread of the disease31. In addition to the reorganization of PHC to relieve the strain placed on health services by the pandemic, it is essential that primary care services maintain routine care without interrupting preventive care and monitoring of chronic diseases such as diabetes and hypertension32. Many regions have therefore adopted remote consultation using ICT, with health professionals also using this technology to share knowledge and experiences and discuss cases33,34.
The regional differences revealed by this study underline the need for a more comprehensive and equitable approach to health management, especially during health emergencies, with increased state and federal funding for less developed regions and the allocation of resources according to the specific characteristics of each region, tailoring strategies to specific needs.
Our findings show that the reorganization of PHC services to respond to the COVID-19 health emergency was undertaken in all the municipalities analyzed, although to a varying degree and with differing focus, according to the availability of equipment and resources in the local health system.
It is interesting to note that different regions adopted different approaches to the reorganization of PHC services, with certain regions, such as the South, showing higher prevalence for modifications to the physical structure of health facilities and others, such as the Northeast and Midwest, standing out for teleconsultation and remote monitoring of at-risk patients and those presenting flu-like symptoms, respectively. These differences may reflect the specific logistical and management challenges faced by each region, as well as different priorities and amount of resources available to deal with the critical phase of the pandemic.
This study has some limitations related to the self-administered questionnaire, which may have resulted in response bias due to the misinterpretation of questions and over and underestimation of data by participants. However, these limitations did not affect the quality of the results, which revealed the complex nature of the response of PHC services to the COVID-19 pandemic in Brazil and the need to tailor approaches to the specific reality of each region. It is essential that health managers consider regional inequities when implementing public health policies and strategies to ensure equitable access to health services and an effective response to health emergencies.
We are grateful to National Council for Scientific and Technological Development (CNPq – Reference code 402507/2020-7).
REFERENCES
1. World Health Organization (WHO). Coronavirus Disease 2019 (COVID-19) / Situation Report - 51 [Internet]. Genebra: WHO; 2020. DisponÃvel em: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
2. Brasil. Ministério da Saúde (MS). Portaria no 2.436, de 21 de setembro de 2017. Aprova a PolÃtica Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017.
3. Fernandes MN da S, Boufleuer E, Finckler PVPR, Trindade L de L, Tavares JP, Dal Pai D. Implications of the COVID-19 pandemic on Primary Health Care: an integrative review. Rev Eletrônica Enferm 2022; 24:70085.
4. Goodyear-Smith F, Kidd M, Oseni TIA, Nashat N, Mash R, Akman M, et al. International examples of primary care COVID-19 preparedness and response: a comparison of four countries. Fam Med Community Heal 2022; 10(2):e001608.
5. Kumar R, Nedungalaparambil N, Mohanan N. Emergency and primary care collaboration during COVID-19 pandemic: A quick systematic review of reviews. J Fam Med Prim Care 2020; 9(8):3856–3862.
6. Kitamura N, Abbas K, Nathwani D. Public health and social measures to mitigate the health and economic impact of the COVID-19 pandemic in Turkey, Egypt, Ukraine, Kazakhstan, and Poland during 2020–2021: situational analysis. BMC Public Health 2022; 22(1):991.
7. Klumpp M, Loske D, Bicciato S. COVID-19 health policy evaluation: integrating health and economic perspectives with a data envelopment analysis approach. Eur J Heal Econ 2022; 23(8):1263–1285.
8. Guedes MBOG, de Assis SJC, Sanchis GJB, Araujo DN, Oliveira AGRDC, Lopes JM. COVID-19 in Brazilian cities: Impact of social determinants, coverage and quality of primary health care. Nunes BP, editor. PLoS One 2021; 16(9):e0257347
9. Bernardeau-Serra L, Nguyen-Huynh A, Sponagel L, Sernizon Guimarães N, Teixeira de Aguiar RA, Soriano Marcolino M. The COVID-19 Vaccination Strategy in Brazil—A Case Study. Epidemiologia 2021; 2(3):338–359.
10. Castro-Nunes P de, Ribeiro G da R. Health equity and vulnerability in the access to COVID-19 vaccines. Rev Panam Salud Pública 2022; 46:1-6.
11. Prado NM de BL, Rossi TRA, Chaves SCL, Barros SG de, Magno L, Santos HLPC dos, et al. The international response of primary health care to COVID-19: document analysis in selected countries. Cad Saude Publica 2020; 36(12):e00183820.
12. Vechi AP de, López Medina IM, Alvarez Nieto C, Uehara SC da SA. Coping with Covid-19 in Primary Health Care: normative documents and mortality. Res Soc Dev 2022; 11(14):e136111436122.
13. 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.
14. Kurotschka PK, Serafini A, Demontis M, Serafini A, Mereu A, Moro MF, et al. General Practitioners’ Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study. Front Public Heal 2021; 9(Supl.1):1–11.
15. 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. Tu WJ, editor. PLoS One 2020; 15(8):e0237629.
16. Hutchings OR, Dearing C, Jagers D, Shaw MJ, Raffan F, Jones A, et al. Virtual Health Care for Community Management of Patients With COVID-19 in Australia: Observational Cohort Study. J Med Internet Res 2021; 23(3):e21064.
17. Brasil. Ministério da Saúde (MS). Protocolo de Manejo ClÃnico do CoronavÃrus (COVID-19) na Atenção Primária à Saúde [Internet]. BrasÃlia: Ministério da Saúde; 2020. DisponÃvel em: https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/protocolo-de-manejo-clinico-do-coronavirus-covid-19-na-atencao-primaria-a-saude/
18. Zou G. A Modified Poisson Regression Approach to Prospective Studies with Binary Data. Am J Epidemiol 2004; 159(7):702–706.
19. Kashiwakura HK, Gonçalves A de O, de Azevedo RR, Nunes A, Silva CAT. A portrait of brazilian primary care: Municipal expenditure and infrastructure in brazilian municipalities. Cienc e Saude Coletiva 2021; 26(Supl.3):3397–33408.
20. Bigoni A, Cunha AR da, Antunes JLF. Provisão de recursos de saúde nas regiões intermediárias do Brasil, 2018. Cad Saúde Coletiva 2023; 31(4):e31040468.
21. Malinverni C, Brigagão JIM, Gervasio MDG, Lucena FS. The role of community health workers in the COVID-19 pandemic: the case of PeruÃbe, São Paulo, Brazil. Cien Saude Colet 2023; 28(12):3543–3552.
22. Schenkman S, Bousquat AEM, Facchini LA, Gil CRR, Giovanella L. Performance patterns of primary health care in the face of COVID-19 in Brazil: characteristics and contrasts. Cad Saude Publica 2023; 39(8):e00009123.
23. Kinder K, Bazemore A, Taylor M, Mannie C, Strydom S, George J, et al. Integrating primary care and public health to enhance response to a pandemic. Prim Health Care Res Dev 2021; 22:e27.
24. CETIC.BR. Pesquisa sobre o uso das tecnologias de informação e comunicação nos estabelecimentos de saúde brasileiros: TIC Saúde 2021: edição COVID-19: metodologia adaptada [Internet]. São Paulo: Comitê Gestor da Internet no Brasil; 2021. DisponÃvel em: https://cetic.br/media/docs/publicacoes/2/20211130124545/tic_saude_2021_livroeletronico.pdf
25. Bender JD, Facchini LA, Lapão LMV, Tomasi E, Thumé E. O uso de Tecnologias de Informação e Comunicação em Saúde na Atenção Primária à Saúde no Brasil, de 2014 a 2018. Cien Saude Colet 2024; 29(1):1–9.
26. Tahsin F, Armas A, Kirakalaprathapan A, Kadu M, Sritharan J, Steele Gray C. Information and Communications Technologies Enabling Integrated Primary Care for Patients With Complex Care Needs: Scoping Review. J Med Internet Res 2023; 25:e44035.
27. Keppel G, Cole AM, Ramsbott1. Keppel G, Cole AM, Ramsbottom M, Nagpal S, Hornecker J, Thomson C, et al. Early Response of Primary Care Practices to COVID-19 Pandemic. J Prim Care Community Health 2022; 13:215013192210853.
28. Lisboa KO, Hajjar AC, Sarmento IP, Sarmento RP, Gonçalves SHR. The history of telemedicine in Brazil: challenges and advantages. Saude e Soc 2023; 32(1).
29. Khalil-Khan A, Khan MA. The Impact of COVID-19 on Primary Care: A Scoping Review. Cureus 2023; 15(1):1–8.
30. Lim J, Broughan J, Crowley D, O’Kelly B, Fawsitt R, Burke MC, et al. COVID-19’s impact on primary care and related mitigation strategies: A scoping review. Eur J Gen Pract 2021; 27(1):166–175.
31. Aquino EML, Silveira IH, Pescarini JM, Aquino R, de Souza-Filho JA, Rocha ADS, et al. Social distancing measures to control the COVID-19 pandemic: Potential impacts and challenges in Brazil. Cienc e Saude Coletiva 2020; 25:2423–2446.
32. Matenge S, Sturgiss E, Desborough J, Hall Dykgraaf S, Dut G, Kidd M. Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature. Fam Pract 2022; 39(4):747–761
33. Cheng A, Angier H, Huguet N, Cohen DJ, Strickland K, Barclay E, et al. Launching a Statewide COVID-19 Primary Care Hotline and Telemedicine Service. J Am Board Fam Med 2021; 34(Supl.1):S170–178.
34. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. What is the role of Primary Health Care in the COVID-19 pandemic? Epidemiol e Serviços Saúde 2020; 29(2):1–4.
