What is the role of Primary Health Care in the COVID-19 pandemic?

Thiago Dias Sarti Welington Serra Lazarini Leonardo Ferreira Fontenelle Ana Paula Santana Coelho Almeida About the authors

Originating in the Province of Hubei, in China, the epidemic unleashed by a new strain of the Coronaviridae virus family (SARS-CoV-2) that causes the disease known as Covid-19 has been spreading rapidly on all continents. 11. World Health Organization. Coronavirus disease (COVID-2019): situation report 72 [Internet]. Genebra: World Health Organization; 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2
https://www.who.int/docs/default-source/...
On March 11 th 2020, just over two months after it began, the World Health Organization (WHO) declared COVID-19 to be pandemic and confirmed over 820,000 cases and 40,000 deaths from SARS-CoV-2 infection as at April 1 st 2020. 11. World Health Organization. Coronavirus disease (COVID-2019): situation report 72 [Internet]. Genebra: World Health Organization; 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2
https://www.who.int/docs/default-source/...
At the time of writing this article, the United States, Italy, Spain and China have the largest number of cases, demonstrating that the virus advances aggressively in places with distinct social and economic characteristics. 11. World Health Organization. Coronavirus disease (COVID-2019): situation report 72 [Internet]. Genebra: World Health Organization; 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2
https://www.who.int/docs/default-source/...

The course and the severity of the epidemic have led many national governments to adopt highly intensive interventions, such as lockdown strategies, with the aim of containing new infections and reducing social overburdening by the disease and its mortality. Such measures have, however, brought an abrupt change in peoples’ lives and in society in general. 22. Parmet WE, Sinha MS. Covid-19 - the law and limits of quarantine. N Engl J Med [Internet]. 2020 Apr [cited 2020 Apr 15];382(15):e28. Available from: https://doi.org/10.1056/NEJMp2004211
https://doi.org/10.1056/NEJMp2004211...
Beyond health issues, the impact of the epidemic on the economic, social, political, and cultural dynamics of the global population has put governance of countries and international agencies to the test, highlighting the limits of globalization.

Despite many individuals still doubting the dimension of the epidemic and despite the nature of the interventions put into practice bringing ethical, political and philosophical issues into the public debate, 33. Agamben G. O estado de exceção provocado por uma emergência imotivada. Revista IHU Online [Internet]. 2020 fev [citado 2020 abr 15];450. Disponível em: http://www.ihu.unisinos.br/78-noticias/596584-o-estado-de-excecao-provocado-por-uma-emergencia-imotivada
http://www.ihu.unisinos.br/78-noticias/5...
the scientific community has stood firm in recommending social distancing as a paramount mechanism for containing the speed at which COVID-19 is transmitted. 11. World Health Organization. Coronavirus disease (COVID-2019): situation report 72 [Internet]. Genebra: World Health Organization; 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200401-sitrep-72-covid-19.pdf?sfvrsn=3dd8971b_2
https://www.who.int/docs/default-source/...
As such, the first governmental responses were targeted above all at disseminating social distancing measures and the race to make intensive therapy unit beds available for severe cases.

The need also exists, however, to discuss the place of Primary Health Care (PHC) in addressing this pandemic, since studies are indicating that some 80% of cases are mild and the majority of moderate cases seek PHC services as the entry point for getting medical care. 44. Dunlop C, Howe A, Li D, Allen LN. The coronavirus outbreak: the central role of primary care in emergency preparedness and response. BJGP Open [Internet]. 2020 Jan [cited 2020 Apr 15]:pii:bjgpopen20X101041. Available from: https://doi.org/10.3399/bjgpopen20X101041
https://doi.org/10.3399/bjgpopen20X10104...
As such, considering the specificities of the Brazilian health system, we intend to discuss some aspects relating to PHC organization and its role in the face of the challenges imposed by Covid-19 in Brazil.

Primary Health Care in the face of the crisis

Preparing a robust system of Primary Health Care Centers to provide quality responses to situations of public emergency is no trivial matter. Brazil has one of the world’s largest universal health systems, anchored in an extensive PHC network, but which is facing chronic funding, management, personnel supply and service structuring problems. 55. Mendonça MHM, Matta GC, Gondim R, Giovanella L, organizadores. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018. Even with these constraints, Brazilian PHC has achieved positive results that make it stand out on the international level. There is overwelming evidence demostrating its significant influence in reducing mortality and health inequities, and this tends to be further potentialized when combined with income transfer and social protection policies. 55. Mendonça MHM, Matta GC, Gondim R, Giovanella L, organizadores. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Editora Fiocruz; 2018.

As such, PHC has to be considered an important mainstay in the face of emergency situations, 44. Dunlop C, Howe A, Li D, Allen LN. The coronavirus outbreak: the central role of primary care in emergency preparedness and response. BJGP Open [Internet]. 2020 Jan [cited 2020 Apr 15]:pii:bjgpopen20X101041. Available from: https://doi.org/10.3399/bjgpopen20X101041
https://doi.org/10.3399/bjgpopen20X10104...
such as the dengue, Zika, yellow fever and Chikungunya epidemics and now the Covid-19 epidemic as well. Emphasizing that which is the very soul of primary care, such as knowledge of the catchment area, access, the link between the service user and the health team, comprehensive care, monitoring vulnerable families and following up on suspected and mild cases, is a fundamental strategy both for containing the epidemic and for people with Covid-19 not becoming severely ill . Responsibility will also fall on PHC in addressing problems arising from prolonged social distancing and the undermining of social and economic life, such as mental disorders, domestic violence, alcoholism and worsening or development of chronic conditions, the consequences of which are hard to foresee and require continuous comprehensive care. All of this comes on top of the set of problems people already live with and which emerge in everyday health service activities.

In order to ensure safe and quality service delivery at this level of health care, the following are therefore necessary: data-based planning, service reorganization according to the characteristics of the epidemic, allocation of financial resources and specific action strategies to address the pandemic that is underway. These include: health workers trained to meet people’s demands with quality, whereby some actions already exist in this direction; 99. Ministério da Saúde (BR). Universidade Aberta do SUS. Atualização: orientações gerais ao paciente com COVID-19 na Atenção Primária à Saúde [Internet]. Brasília: Ministério da Saúde; [2020] [citado 2020 abr 15]. Disponível em: https://www.unasus.gov.br/cursos/curso/46168
https://www.unasus.gov.br/cursos/curso/4...
large quantities of diagnostic tests, if mass testing is opted for; structure for requesting complementary tests with timely results; adequate physical facilities to accommodate possible suspected cases arriving at health services; medication stocks; well-defined workflows and protocols – like those already developed and constantly updated by the Ministry of Health, 1010. Ministério da Saúde (BR). Protocolo de manejo clínico do coronavírus (Covid-19) na Atenção Primária à Saúde [Internet]. Brasília: Ministério da Saúde; 2020 [citado 2020 abr 15]. 32 p. Disponível em: https://www.saude.gov.br/images/pdf/2020/marco/20/20200318-ProtocoloManejo-ver002.pdf
https://www.saude.gov.br/images/pdf/2020...
with priority access to other health service levels, so as to potentialize PHC health care coordination; support for diagnostic support and care shared with health teams; sufficient health workers, including Community Health Agents, to carry out surveillance in community and household settings; adequate personal protective equipment in sufficient quantities for health workers and symptomatic individuals; and organization of work processes that efficiently interlink methods relating to service access, care for people and production of information capable of providing feedback to the service and the system in a timely manner, thus strengthening care delivered to the population.

PHC is powerful in reducing health inequities 1212. Hone T, Rasella D, Barreto ML, Majeed A, Millett C. Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: a national longitudinal analysis. PLoS Med [Internet]. 2017 May [cited 2020 Apr 15];14(5):e1002306. Available from: https://doi.org/10.1371/journal.pmed.1002306
https://doi.org/10.1371/journal.pmed.100...
and must, therefore, be strengthened and structured as one of the main health sector responses to the epidemic, given that it is highly spread across the national territory and reaches sizeable groups of the population exposed to excessive risks due to their living conditions. Pandemics such as COVID-19 bring to a standstill discourses and practices aimed at reducing the size of the State, flexibilizing labor laws, dismantling the social protection system, disparaging and downscaling investment in science, technology and education, and undermining public health services. 1313. PerifaConnection. O coronavírus mata, mas a desigualdade social acelera o óbito. Folha de São Paulo [Internet]. 2020 Mar [citado 2020 abr 15]. Disponível em: https://www1.folha.uol.com.br/colunas/perifaconnection/2020/03/o-coronavirus-mata-mas-a-desigualdade-social-acelera-o-obito.shtml
https://www1.folha.uol.com.br/colunas/pe...
The crisis is clearly not just a health issue, but rather is closely intertwined with political, social and economic issues, which require a set of measures that go beyond immediate contention of the virus transmission chain. In an increasingly complex and unpredictable world, the challenge arises of planning what social model and health system should be strived for in order to protect lives, especially those of the most vulnerable.

Telehealth as a care option

The facility with which the virus infects people, its high potential for spreading in closed spaces, such as hospitals and emergency services, as well as the need to avoid mass utilization of health services in the initial stages of the epidemic, make telehealth services a fundamental care strategy, enabling service users to get reliable information in a timely manner about how to proceed on the individual level. 1414. Dorsey ER, Topol EJ. Telemedicine 2020 and the next decade. Lancet [Internet]. 2020 Mar [cited 2020 Apr 5];395(10227):859. Available from: https://doi.org/10.1016/S0140-6736(20)30424-4
https://doi.org/10.1016/S0140-6736(20)30...
Greenhalgh et al. 1515. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ [Internet]. 2020 Mar [cited 2020 Apr 15];368:m998. Available from: https://doi.org/10.1136/bmj.m998
https://doi.org/10.1136/bmj.m998...
point out that on-line care services can be important tools in cases of people with high levels of anxiety and/or symptoms suggesting mild or moderate Covid-19.

This epidemic has imposed changes to the legal framework governing telehealth practices in Brazil, leading the Federal Council of Medicine to recognize the use of telehealth tools by medical professionals with the aim of guiding, referring and monitoring suspected or positive coronavirus cases. 1616. Conselho Federal de Medicina (BR). Ofício CFM nº 1756/2020 – COJUR [Internet]. Brasília: Conselho Federal de Medicina; 2020 [citado 2020 abr 14]. Disponível em: http://portal.cfm.org.br/images/PDF/2020_oficio_telemedicina.pdf
http://portal.cfm.org.br/images/PDF/2020...
Based on this, the Ministry of Health has regulated the use of telemedicine exceptionally for the context of the Covid-19 epidemic, 1717. Brasil. Ministério da Saúde. Portaria MS/GM nº 467, de 20 de março de 2020. Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3º da Lei nº 13.979, de 6 de fevereiro de 2020, decorrente da epidemia de COVID-19 [Internet]. Diário Oficial da União, Brasília (DF), 2020 mar 23 [citado 2020 abr 14];Seção 1:Extra. Disponível em: http://www.in.gov.br/en/web/dou/-/portaria-n-467-de-20-de-marco-de-2020-249312996
http://www.in.gov.br/en/web/dou/-/portar...
for the purposes of pre-clinical assessment, support with care, consultations, follow-up and diagnosis throughout the entire Brazilian health system. This has been a fundamental step for telecare being officially included on the national clinical protocol for this problem within the context of PHC. 1010. Ministério da Saúde (BR). Protocolo de manejo clínico do coronavírus (Covid-19) na Atenção Primária à Saúde [Internet]. Brasília: Ministério da Saúde; 2020 [citado 2020 abr 15]. 32 p. Disponível em: https://www.saude.gov.br/images/pdf/2020/marco/20/20200318-ProtocoloManejo-ver002.pdf
https://www.saude.gov.br/images/pdf/2020...
This has resulted, among other things, in state and municipal health services adopting telecare call centers as essential components for people’s first contact with the health care network.

Adequate implantation of these technologies increases the health system’s capacity to meet demand, facilitates people’s access to reliable guidance, contributes to reducing overburdening of PHC and other health care levels, as well as assisting organization of the flow of people though the system. Moreover, in view of the potential for many health workers having to stay away from work during the epidemic, telehealth is a possibility for them to work remotely.

However, these services should not operate just as an additional care network service, nor only during this period of the fight against Covid-19. The benefits of telehealth tools for the system indicate the importance of them being adopted in a more widespread manner throughout the Brazilian National Health System (SUS) and, in particular, in a manner integrated with PHC. This measure, if it is duly implemented at this level of care, can lead to positive results in terms of access, resolutive capacity, comprehensiveness and scope of care, convenience for service users and improved monitoring of people with chronic diseases who currently get follow-up at health centers.

In order for the telehealth experience to truly become a reality in PHC and the SUS, however, the Ministry of Health needs to make a massive investment in this area, both with regard to guaranteeing internet access at health centers, as it has been announcing, and also with regard to purchasing computers and telephones, as they are fundamental for establishing satisfactory communication. On the other hand, the mistrust of some health workers regarding this form of care delivery, the lack of electronic medical records having an interface with e-SUS and the impossibility of issuing prescriptions and requesting tests and examinations, duly signed electronically and certified, are barriers that need to be overcome, through the necessary and urgent revision of the legal provisions regarding the practice of telemedicine in Brazil.

We need to learn from the crisis

Universal public health systems anchored in robust, resolutive, comprehensive, accessible and socially and culturally oriented Primary Health Care are one of the mainstays of a society that respects people’s most elementary rights. Jones, 1818. Jones DS. History in a crisis - lessons for Covid-19. N Engl J Med [Internet]. 2020 Mar [cited 2020 Apr 15]. Available from: https://doi.org/10.1056/NEJMp2004361
https://doi.org/10.1056/NEJMp2004361...
based on the work of Rosenberg, emphasizes that times like these, i.e. addressing an epidemic on this scale, bring to light realities that were previously not very evident. It is possible that global problems such as we are currently facing become more frequent. For this reason, there is no room for ideas that put human life in second place.

PHC needs to urgently take on its protagonism as the organizer of health care in the SUS. Some measures, such as reorganizing patient flows in services, can and must be taken immediately. Others, such as improving the physical structure of health centers, should remain on the horizon, as it is known that they take more time to be implemented. For all these measures, APS needs to be put at the core of the Ministry of Health’s agenda and the SUS must not be strangled by constitutional amendments that restrict the scarce resources the Union allocates to the health sector. The success of overcoming Covid-19, the future of the SUS and the health of the Brazilian population depend on this.

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    » https://doi.org/10.1016/S0140-6736(20)30424-4
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    » https://doi.org/10.1136/bmj.m998
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Publication Dates

  • Publication in this collection
    27 Apr 2020
  • Date of issue
    2020
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com