Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil

More than 30 years into the anniversary of the Unified Health System (SUS), 40 years after Alma-Ata, and soon after the Astana Conference, the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS). This paper presents the process of developing the national PHC service portfolio, one of the strategies developed by SAPS to strengthen the PHC clinic, and the challenges for the expansion of comprehensive care in the actions developed by the Family Health and Oral Health teams. After the public consultation, from a total of 209 initially listed actions and procedures, including incorporations and exclusions, 210 items were defined, including the actions planned for the integration between primary care and health surveillance. We emphasize that the national portfolio model can be adapted to the reality and municipal context in each of the federation units, including considering the availability of the local care network.


introduction
In August 2007, the Pan American Health Organization (PAHO) announced that the first approach to producing sustainable and equitable improvements in the health of the populations of the Americas is developing health systems firmly based on Primary Health Care (PHC) 1 . In 2008, in its World Health Report, WHO reinforced this guideline with the statement that gives name to that publication Primary Health Care Now More Than Ever! 2 More recently, in October 2018, when Alma-Ata completed 40 years, the Global Conference on PHC produced the document entitled the Astana Declaration, which stresses that PHC is the most effective, efficient and equitable approach to improving health, making it a necessary foundation for achieving universal health coverage 3 .
Upon completing 30 years of the SUS, 40 years after Alma-Ata 4 and shortly after the Astana Conference 3 , the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS) 5 . As SAPS competences and commitments, defined by the decree above, worth highlighting are expanding the population's access to family health units, defining a new financing model based on health and efficiency results, defining a new model of supply and training doctors for remote areas, strengthening the PHC clinic and teamwork, and expanding the computerization of the units and the use of electronic medical records.
The strengthening of the clinic and teamwork in the Family Health Strategy (ESF) requires the recognition of federated entities of the importance of PHC for the organization of services. Thus, besides the physical infrastructure of the Family Health Units (USF), one must have working conditions and a clear division and subsidiary attributions of each of the professionals from the actions and procedures provided to the population, without prejudice to the shared care processes among professionals. In this sense, the creation of a "primary health care portfolio" may define the individual roles, besides fundamentally presenting the procedures and services offered in this care environment, reducing the heterogeneity of existing practices in the national PHC between municipalities, but also between facilities in the same municipality, so that the Brazilian population can recognize what is expected from actions and services in a Family Health Unit.
Universal health systems are sustainable if they have strong PHC 6,7 . PHC aims at a better individual and population health with equity, which is only achieved if the PHC services work correctly, that is, they combine high clinical resolution with accountability for the health of the population under care, and the adequate communication of the facts and events that characterize people's clinical path. PHC must be organized with the maximum presence and extent of its operational characteristics and attributes to achieve the above objectives and function properly. The essential attributes of Primary Care (first contact access, longitudinality, coordination, and comprehensiveness) are operational and measurable characteristics of PHC services 8 . The stronger the presence and extent of these attributes, the more robust the PHC will be. Different and complementary organizational tools are required to strengthen each attribute.
In Brazil, the PHC portfolio is one of the most important organizational tools. It is already used in Rio de Janeiro, Curitiba and Florianópolis, among other places [9][10][11] . It is a vital instrument to ensure comprehensiveness. PHC must be organized in such a way to provide citizens with all the necessary health services, identifying and providing preventive services, as well as services that enable the diagnosis and treatment of diseases, also establishing the appropriate way to solve organic, functional, or social problems.
By defining a transparent list of actions and services aimed at the most frequent health problems and conditions, we have the necessary 'leverage' to move the 'world' of comprehensiveness and bring it into the daily lives of people and PHC teams. The PHC portfolio makes it clear to people what services and actions they can find in the PHC facilities, and allows professionals to organize themselves in the service routine, as well as seek knowledge and skills to offer the actions and services with competence. Moreover, the portfolio becomes an instrument for monitoring management, which must provide the structural conditions (equipment, inputs, human resources, financing) and the work process -people deployment, continuous personal development strategies, monitoring, and evaluation -enough to make their actions and services a reality in the day-to-day life of PHC.
Intended for professionals in the Health Care Network (RAS), it contains the definition of PHC responsibilities to ensure, primarily, the care comprehensiveness attribute. It seeks to establish general organizational guidelines and define actions and procedures provided in each service based on virtually structural criteria.
PHC must be responsible for the most common and frequent health problems of the population and resolve 80% to 90% of their demands. From a clinical viewpoint, the PHC Portfolio does not aim to list or exhaust all the most prevalent signs/ symptoms or pathologies that must be managed and monitored by PHC, especially since the epidemiology and people's needs are dynamic and varying, mainly when referring to a country with continental dimensions like Brazil. Yet it is worth mentioning that the procedures and actions to be carried out must respect the specific regulations of the professional councils, as well as individual skills, and are the motto for the organization and the identification of additional necessary training. The central objective of the PHC portfolio is guiding professionals concerning services that are expected to be provided in PHC units (especially in the context of the SAPS and MoH guidelines and goals), and whether any particular condition for this service to occur (table of actions/programs and materials) is in place. Furthermore, it serves to reinforce which criteria are indicative of handling common conditions or complaints at a higher level of complexity in the municipality's network, on an elective basis (not including emergencies). It is a document that is not intended to be exclusive. Therefore, the absence of mention of a sign, symptom, or disease does not mean that you should not be attended at the PHC.
This paper aims to show the development of the national PHC portfolio of services and the challenges for strengthening comprehensive care in the actions developed by the Family Health and Oral Health teams.

Material and methods
This is a study with a documentary analysis that aims to produce technical guidance to assist PHC teams and management at the state and municipal level in defining the provision of actions and services in family health units. The so-called "Primary Health Care Portfolio" (CASAPS) is a document that aims to guide health actions in Brazilian PHC with recognition of the multi-professional clinic. It is a guiding document for all Brazilian PHC services and is, thus, an instrument that aims to contribute to the strengthening of PHC's care supply. It is an essential care management tool that will be regularly reviewed by the SAPS, and is intended for all professionals, managers, and Brazilian citizens to take owner-ship and have knowledge of the health services offered in PHC. One of its versions is specifically aimed at professionals and managers and contains the list of services and necessary supplies and equipment (Table 1).
We considered the following materials for its preparation: (i) review of national and international documents with PHCportfolios. Initially, a comprehensive review of PHC portfolios published in Brazil and abroad was carried out. As it is a tool rarely used in our country, we reviewed portfolios in Rio de Janeiro, Florianópolis, Curitiba (Services Portfolio and Access Booklet), Belo Horizonte, Natal, and Porto Alegre. The portfolios of services in Portugal, Spain, and the city of Madrid were also revised; (ii) revision of the Primary Care Assessment Tool Manual (PCATool) published in 2010 by the Ministry of Health 12 .
All the services described in the portfolios of the municipalities mentioned above were listed, and a comparison was made between them, building a table with the list of terms and verification of the cities where the service was present in the portfolio. The services were divided and shown as follows: adult and older adult health care, child and adolescent health care, and PHC and oral health procedures. Moreover, we elaborated a guiding text regarding the work process of health teams in PHC, and PHC's essential attributes were the principal axes.
The stages of the public consultation were: (i) interaction with external evaluators to contribute to the elaboration of the portfolio's content; (ii) provision of the draft service portfolio during the public consultation period on the Ministry of Health Portal, along with a form on the Google Forms Platform in August 2019. At this point, participants expressed their opinion for inclusion or exclusion and could suggest changes for each item of the list of actions and procedures 13 (iii) review after public consultation by SAPS of the introductory text and the list of actions and services presented.

The contribution of Professional Associations, the National Council of State Health Secretaries (CONASS) and the National Council of Municipal Health Secretaries (CONASeMS)
Besides other Secretariats of the Ministry of Health, the proposal was sent to CONASS, CONASEMS, and the Professional Associations of the Brazilian Society of Family and Community Medicine (SBMFC), the Brazilian Association of Family and Community Nursing (ABEFA-CO) and the Brazilian Association of Dentistry (ABO), which were called external evaluators. Such entities were approached both during the public consultation period and later, on the final version of the portfolio resulting from the public consultation. At this stage, these bodies also gave their opinion on the classification in essential and expanded PHC standards provided for in the PNAB.

results of the final version of the portfolio of services
A quantitative and qualitative analysis of the responses sent by electronic forms was conducted after the public consultation. In all, 1,855 forms were answered, distributed from the respondent's profile as follows: 1,415 (76.3%) health professionals, 86 (4.6%) SUS users, 81 (4.4%) students, 121 (6.5%) municipal managers, 28 (1.5%) state managers, 17 (0.9%) Ministry of Health managers, 44 (2.4%) researchers and 63 (3.4%) identified in the "others" category.
The level of agreement (people who marked "I agree with the inclusion" or "I agree with the inclusion, with changes") was high ( Table 1). The item with the lowest percentage of agreement (46.7%) was: "Identification regarding the possession of a firearm by adults and guidance on how to store it safely". A low agreement was also observed with the PHC procedures, among which the following stand out: "infiltration of substances in the synovial cavity (joint, tendon sheath) (70.8%)", "biopsy/puncture of superficial skin tumors and sending the material for anatomopathological analysis" (73.9%) and "manual removal of fecaloma" (74.1%).
When we analyzed the contributions and changes made from a qualitative viewpoint, after the public consultation, we highlighted six relevant points: (i) addressing what belongs to PHC, and the need for protocols, articulating with the network; (ii) the inclusion of an item that considered the promotion of integrative and complementary practices; (iii) mentioning that some items in the portfolio will be challenging to execute concerning exams and procedures, considering the infrastructure of some facilities; (iv) the inclusion of items that measure the assessment of frailty and multidimensional assessment in older adults; (v) in the text that precedes the list, it would be necessary to mention the need for the PHC team to be supported by other services in the care network; (vi) the need for reinforcement and the possibility of adapting the portfolio to the local reality.

The reorganization of portfolio items
The assignments for higher education professionals were considered in the construction of the final version of the portfolio, keeping the essential attributes in the "Child/Adolescent", "Adult and Older Adult", "PHC Actions/Procedures", and "Oral Health" groups, thus considering the work process of doctors, nurses and dentists. From a total of 209 actions and procedures initially listed in the public consultation, including inclusions and exclusions, at the end of its creation, 210 items were defined, including the set of actions planned for the integration between primary care and health surveillance. The vital contribution from the public consultation with the change and qualification in the text of 109 items in total is also cited: 44 items changed to "Adult/Older Adult", 27 to "Child/Adolescent", Women care during the climacteric period. 4 Approach to sexual and reproductive health: individual and group guidance on contraceptive methods; risk management; offering and dispensing preventive supplies and rapid tests; sexual dysfunctions; preconception assessment; early pregnancy diagnosis and guidance on marital infertility. 5 Management of the most common gynecological problems: abnormal uterine bleeding, fibroids, vaginal discharge (syndromic approach), and pelvic pain. 6 Prevention, identification, reception, and monitoring of situations of violence against women, sexual, intra-family, and gender violence, preferably in intersectoral partnership with social assistance and public security services. 7 Promotion of breastfeeding and management of common breast problems related to lactation. 8 Screening for cervical cancer and monitoring of women diagnosed with cervical cancer. 9 Screening for breast cancer and monitoring the person diagnosed with breast cancer. 10 Monitoring of adults and elderly in palliative care, with guidance to family members/caregivers. 11 Assistance to vulnerable populations, such as people living in the streets, gypsy, quilombola, people deprived of liberty, among others. 12 Monitoring of people with work-related diseases. 13 Epidemiological analysis of the local health situation. 14 Performing notifications and health surveillance actions. 15 Home care for people who are restricted to bed/bedridden, with no mobility, as well as in situations with an indication of home evaluation after death, or resistance to treatment. 16 Home care for older adults restricted to the home or with mobility difficulties, including information, health guidelines, counseling, and support for relatives/caregivers. 17 Identification and monitoring of vulnerable older adults, at risk of functional or fragile decline (multimorbidities, polypharmacy, recent hospitalizations, sphincter incontinence, recurrent falls, changes in gait and balance, cognitive impairment, sensory impairment, unintentional weight loss, difficulty in chewing or swallowing, signs and symptoms of mood disorders, family insufficiency, social isolation, suspected violence, degree of dependence for activities of daily living) with the establishment of a care plan adapted to each case. 18 Prevention, identification, reception, and monitoring of situations of violence against older adults, preferably in intersectoral partnership with social assistance and public security services. 19 Prevention of domestic accidents, falls, and fractures. 20 Promotion of active and healthy aging. 21 Prevention, identification, treatment, and monitoring of nutritional disorders in adults and older adults. 22 Screening and counseling for drug abuse and polypharmacy. 23 Immunization as per the vaccination schedule of adults and older adults, watching for situations of outbreaks of vaccine-preventable diseases and specific clinical situations. 24 Identify and accompany adults and older adults in social assistance or social benefits programs. 25 Promoting the adoption of healthy lifestyle habits, such as adequate and healthy food, body practices and physical activities, control of alcohol, tobacco, and other drugs, among others. 26 Prevention, active search, diagnosis, treatment, and monitoring of people with leprosy. 27 Prevention, screening for respiratory symptoms, diagnosis, treatment, and monitoring of people with Tuberculosis (first-line treatment, directly observed treatment, screening for respiratory symptoms, and search for contacts of patients with pulmonary tuberculosis). 28 Prevention, identification, and counseling regarding the abuse of alcohol and other drugs. 29 Prevention, identification, counseling, and treatment concerning tobacco use. 30 Prevention, screening, diagnosis, treatment, and monitoring of people diagnosed with Syphilis, Viral Hepatitis, other STIs, and people living with HIV, with special attention to key populations. 31 Promotion of responsible and active parenting. 32 Screening for colon and rectum neoplasia in people between 50 and 75 years old. 33 Tracking and monitoring of DM2 in asymptomatic adults. it continues

Adult-and elderly-centered attention and care
Child and adolescent-centered attention and care 59 Immunization as per to the Child and Adolescent's Vaccination Calendar, guidance to parents or guardians, evaluation and monitoring of the vaccination situation, and active search for absentees. 60 Prevention, identification, treatment, and monitoring of situations related to nutritional disorders (underweight, malnutrition, overweight, and obesity). 61 Child health screening: neonatal screening (foot test and red reflex) and early identification of heart murmurs. 62 Performing notifications and health surveillance actions. 63 Epidemiological analysis of the local health situation. 64 Surveillance of at-risk/vulnerable newborns based on the records and reports supplied by maternity hospitals. 65 Nutritional supplementation (vitamins, minerals, formulas) -when indicated. 66 Prevention, active search, diagnosis, treatment, and monitoring of children and adolescents with leprosy. 67 Prevention, screening of respiratory symptoms, diagnosis, treatment, follow-up, and investigation of contacts of children and adolescents diagnosed with tuberculosis. 68 Monitoring children with microcephaly / Zika virus. 69 Prevention, screening, diagnosis, treatment, and monitoring of children and adolescents with syphilis, viral hepatitis, HIV, and other STIs. 70 Prevention, identification, counseling, and treatment concerning tobacco use. 71 Prevention, identification, and counseling regarding alcohol and other drugs' abuse. 72 Prevention, identification, reception, and monitoring of situations of violence against children and adolescents, preferably in intersectoral partnership with social assistance and public security services. 73 Prevention and promotion of the safety of children and adolescents against physical injuries: the safety of pedestrians, passengers of motor vehicles and bicycles, prevention of drowning, burns, falls, firearms accidents, and intoxication. 74 Monitoring of children and adolescents with palliative care needs, offering guidance to relatives/ caregivers. 75 Home care for children and adolescents bedridden, unable to move, in some post-death situations, or resistance to treatment. 76 Identification and monitoring of children and adolescents with learning difficulties and problems related to the school context or child labor. 77 Identification and monitoring of children and adolescents with physical or mental disabilities. 78 Identification and management of growth and development problems in childhood and adolescence. 79 Identification and follow-up of children and adolescents in situations of vulnerability (violence, child labor, socio-educational measures, institutional care, homeless people, migrants, and refugees). 80 Meeting self-referred demand with risk assessment. 81 Urgent/emergency care for children and adolescents. 82 Identification and management of the most common problems of newborns and infants: infant colic, regurgitation, and vomiting, intestinal constipation, oral moniliasis, miliaria, diaper dermatitis, impetigo, seborrheic dermatitis, jaundice, navel problems, inguinal hernia and hydrocele, retained testicle, developmental dysplasia of the hip. 83 Identification and management of serious health conditions in children under 2 months: convulsions, lethargy/flaccidity, respiratory effort (subcostal retraction, nasal flapping, apnea), groaning/stridor/ wheezing, central cyanosis, intense pallor, abdominal distention, weight <2000g, slow capillary filling (> 2s), pustules or vesicles on the skin, manifestations of bleeding (ecchymosis, petechiae or hemorrhages), purulent discharge from the ear or conjunctiva. 84 Identification and management of the most common childhood problems: asthma, iron deficiency and anemia, intestinal parasites, fever, upper airway infections, overweight in children, acute diarrhea, allergic rhinitis, allergic eczema, urticaria/angioedema, allergy to an insect bite. 85 Assistance to the prevalent adolescence problems: pubertal delay, precocious puberty, acne, scrotal pain (cryptorchidism, testicular torsion, epididymitis, varicocele), pubertal gynecomastia, dysmenorrhea, obesity, vulvovaginitis.

Chart 1. List of services of the Portfolio of Primary Health Care Services in Brazil -CASAPS.
it continues

Child and adolescent-centered attention and care
17 to "PHC Procedures", and 21 to "Oral Health". Moreover, the details of supplies, equipment, and even the technical references necessary for the performance of each action/procedure by the team were included. We emphasize that the model of the national portfolio can be adapted to the reality and municipal context in each of the federative units, also considering the availability of the local care network.

Discussion
The service portfolio is a document that aims to guide health actions and presents itself as the regulator of PHC in the places where it was implemented. Its content covers the set of care and clinical, health surveillance, promotion, and prevention activities offered as services that aim to improve the quality of care in PHC. For the current management of the Ministry of Health and SAPS, it is part of the PHC clinic strengthening process, establishing itself as a guide for users of health services, for PHC professionals and other levels of care and health care, and managers. The starting point for the elaboration of this document was the review and evaluation of service portfolios implemented in important Brazilian cities. As a managerial innovation strategy, the municipality of Rio de Janeiro adopted the service portfolio in PHC in 2010 9 . Similarly, after this movement started in the capital of Rio de Janeiro, important Brazilian cities followed in the same line, with the development of their municipal document. This occurred in Curitiba, Florianópolis, Natal, Belo Horizonte, and, more recently, in Porto Alegre 10,11,[14][15][16] . The initiative to develop PHC portfolios at the municipal level was encouraged by some Brazilian state health secretariats. Even so, nine years into the first publication of the document in Rio de Janeiro, considering all the 5,570 Brazilian municipalities, we can observe that a very minimal number of cities are equipped with their document, failing to supply and describe with transparency for its population the clinical, health surveillance and preventive spectrum offered by its PHC/ESF teams. In this sense, the national portfolio prepared by the Ministry of Health aims to assist municipal managers in the implementation of a list of PHC actions and services. It is a document that is not intended to be exclusive since the failure to mention a symptom, sign, diagnosis, action, or care does not mean that it should not be performed in PHC. This tool must be revised periodically, giv-en the natural change in the health maintenance and illness process. It is structured with an emphasis on the essential attribute, namely, Comprehensiveness and divided into Attention and Care Centered on the Adult and Older Adult, Child and Adolescent, PHC Procedures, and Oral Health Attention and Care. Among the problems it seeks to solve, worth mentioning is the concentration of patients at the secondary and tertiary levels of health care seeking PHC procedures, such as removing cerumen and treating the ingrown nail, for example. However, the challenge of strengthening the clinic transcends performing more complex procedures or interventions in the PHC environment. It also involves monitoring and resolute care for highly prevalent and relatively low-complexity clinical problems such as Systemic Arterial Hypertension and Type 2 Diabetes Mellitus. And this is becoming increasingly more important over the years, and with the consequent more significant number of older adults in our population: caring, addressing, managing and working with the prevention of chronic non-communicable diseases, at the individual, family and community level, is one of the relevant PHC roles listed in the Brazilian portfolio. When describing 210 actions and services typical of the PHC environment, distributed by the PHC clinic, health surveillance, health promotion, and prevention activities and a family and community approach, the service portfolio proposes a quality challenge in healthcare, which also involves the challenge of training and qualifying the scope of PHC professional practice, stimulating the clinical training of doctors, nurses, and dentists, and regulating the need for training through Family and Community Medicine, Family and Community Nursing, and Dentistry residency programs in PHC.
PHC is the organizer of health systems, but it still has to improve its efficiency 17 to perform this function knowledgeably. Studies that set out to investigate the presence and extent of PHC attributes in Brazil indicated that the services have low PHC orientation, especially when the essential attributes are observed [18][19][20][21][22] . Comprehensiveness still seems to be one of the most consistent challenges among the essential attributes. The low performance of this attribute may be related to the organizational incapacity of PHC teams to provide services, and their heterogeneity thereof. From this perspective, it is essential to note that a set of structured actions to strengthen PHC is essential to gain efficiency. This involves an organized health care network with established flows, continuous improvement of access, investments in family and community medicine and multi-professional residencies, and the definition of a portfolio of services that meets the needs of the population.
Another important managerial function provided by the service portfolio is to assist with the production of the list of supplies and physical structures necessary for the execution of the procedures and services by the professionals of the PHC teams. In this sense, in its complete version for professionals and managers, the Brazilian PHC Portfolio presents the list of necessary supplies in its description structure for each service, as well as a brief excerpt of guidelines related to the topic, followed at the end by the "Learn more" section, where the service of the item under evaluation is referenced to the clinical contents elaborated and present in the Ministry of Health materials (Primary Care Notebooks, Protocols, and other).
It is important to note that the service portfolio plays a vital role in inducing a more significant offer of actions and procedures by PHC teams. This characteristic was shown in a study that identified the offer of actions and procedures by the Family Health teams, based on the Services Portfolio of the Municipality of Rio de Janeiro 9 , and that compared the city of Rio de Janeiro with other places divided by population strata 23 . This study concluded that the city of Rio de Janeiro showed a better performance when compared to the average of large cities concerning the provision of health actions and services.
When comparing the Brazilian portfolio with that of other countries, mainly the Portuguese and Spanish portfolios 24,25 , we see that the list established for the Brazilian scenario includes the implementation of a strong and comprehensive PHC in all its aspects. Following the model and example used mainly in the Spanish PHC portfolio, in a next review, we will be able to incorporate the description and definition of the indicators used for monitoring and evaluating PHC in the country into the Brazilian portfolio, thus further emphasizing the principle of transparency in SAPS' actions.
The most important principle of the current management of SAPS is to put people first, that is, to strengthen the SUS so that it is factually a health system that places people at the center, consolidating itself as a person-centered health system. This system is manifested by a strong and clinically resolute PHC, with transparency, monitoring, evaluation, and providing autonomy and flexibility for the management process carried out in each Brazilian city. The service portfolio does this by placing people at the center of the process and contributing to the strengthening of PHC's care offer. In the same way, it provides transparency when describing the list of PHC actions and services for the whole society, contributing to the monitoring, evaluation, and management processes by allowing the construction of some monitoring indicators for the implementation of the health services listed in the portfolio.

Collaborations
CRH Cunha worked on the design, elaboration, methodology, analysis of results, and the final drafting. E Harzheim worked on the design and final drafting. OL Medeiros worked on the design, methodology, analysis of results, and the final drafting. OP D'Avila worked on the design, analysis of results, and final drafting. W Lucas, LA Faller and C Martins worked on the final essay.