Primary health care in CSP

The search for primary health care (PHC) focused on people, families and territories, synergistic to the population’s health needs and to the principles of the Brazilian Unified National Health System (SUS), is a fruitful and priority field for scientific production and dissemination. Over the course of approximately 30 years of implementation and consolidation of the Family Health Strategy (FHS) as a priority model of PHC in SUS several successful outcomes have been achieved; however, research results suggest some health issues are yet to be resolved, the resurgence of old problems and the advent of new challenges, the most recent being the COVID-19 pandemic.

In 2008, Reports in Public Health/Cadernos de Saúde Pública (CSP) published a thematic supplement with an important Editorial ¹ and Debate ^{2,3,4,5,6,7,8} about the challenges of FHS for the organization and strengthening of PHC in Brazil; the country’s national policies and programs since the 2010s sought, in some way, to face them. More recently, the journal has also fostered reflections about the deconstruction policies of FHS’s trajectory from central elements such as its conception, organization and financing, while the directionality failed to respond to recognized problems, nor do they offer new perspectives that have universality and solidarity as values ^9,10.

The wide diversity of themes of this great field of research and practices that make up PHC is reflected in the manuscripts published by CSP over 345 issues (until July 2022), available free of charge for public access since 1985. Even if the journal does not comprise the whole of the production on FHS, we chose to consider, in this reflection, the articles published since 2000 - because that year is a milestone in the expansion and evaluation of FHS in Brazil ¹¹. This retrospective invites us to identify the main topics already addressed and those not yet sufficiently explored in the publication about FHS/PHC in CSP.

The first decade of the 2000s presents us with a diversity of publications centered on the representations, attitudes and perceptions of users living with some health problem. We identified analyses related to access and reception, the attribute of care coordination, evaluation of the organization, offer of different care practices and adequacy of the program to ministerial standards, in addition to federal choices in financing and expansion. Topics such as pharmaceutical care, mental health, prenatal care and evaluation of oral health implantation under FHS also permeated the productions. Publications with results of research on the implementation/organization of FHS, evaluation/monitoring of priority programs, as well as analyses of the Brazilian Family Health Strategy Expansion Program (PROESF) appear as important contributions, at that time, to ratify the directionality of policies, organization of the system and practices in the direction of FHS.

From 2011 onward, we noticed a progressive growth in the number of productions related to PHC in CSP, roughly following the developments of national policies aimed at improving the quality, resolution and provision of the workforce. Such challenges had been identified in the previous decade and evidenced in the studies that accompanied the expansion of FHS in the country. The journal kept publishing analyses of implementation, of guidelines, of coverage, of the most varied actions and priority areas in the field of care, of practices of community health agents, of themes related to work and workers, to matrix support/Extended Centers of Family Health, to Integrative and Complementary Practices in Health, to networks of care/coordination/continuity of care, to the More Doctors Program and to themes related to the provision, financing and organization of FHS and, recently, PHC and COVID-19 via a fast track editorial policy.

In the same period, following the previous decade trend, the effects of policies, the progressive increase in coverage and actions in oral health stand out in the publications. Evaluations of attributes and comparison between care models, especially with the use of the Primary Care Assessment Tool (PCATool) and the ambulatory care sensitive conditions (HACSC) are among the productions to evaluate PHC performance, indicating, in general, more positive results of FHS when compared to other care modalities. International analyses had space, to a lesser extent, mainly those of South American contexts and some European ones, especially Portugal. The large volume of information produced from the three cycles of the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB) generated many analyses on the various aspects of PHC: infrastructure of basic health units, quality of actions, information and communication technologies, integration and coordination of care, professional perception, availability of vaccines, School Health Program, among others.

Over the course of the productions analyzed in CSP for this Editorial, which covered a little more than two decades, in addition to the studies “about” PHC, research about the interventions “in” PHC emerged, demonstrating the strength of knowledge produced territorially to face inequalities and recognize the specificities and diversity characteristics of our continental-size country. Still, a certain saturation in the exploration of some national “public domain” databases seems to exist, because, even if holding relevant knowledge and analyses, such databases would benefit from complementarity and diversity in theoretical-methodological approaches to express the local and regional innovations necessary for the (re)formulation of sectoral policies.

As a result of this exercise of reflection and self-criticism, we risk saying that themes linked to the attributes derived from and the territorial dimension of PHC, quality of care, ease of use, experience/itinerary of users, highlighting aspects related to dignity, non-discrimination, autonomy and diversity, also seem, to us, inviting fields to methodological diversification in scientific publication. Given the complexity that circumscribes the production of health care in a world whose dynamics are based on a neoliberal society ¹², we believe that the effort to recover or build other perspectives must be urgent, achieving a production of knowledge that includes the different social subjects.

A permanent challenge is the search for paths that are not as hegemonic in the production “about” and “in” PHC. In this sense, South-South cooperation in the production of knowledge and analyses is an invitation to overcome the tradition of looking only at the successful cases in PHC of European tradition, while the experiences and knowledge produced in the interstices of the territories of the global south are concealed. Moreover, scientific publication must be permanently sensitive to the internal logics of the different social groups that experience the daily problems that studies about/in PHC seek to respond, among which those related to the health of black and LGBTQIA+ populations, peoples and populations living in rural areas, forests and waters, using only some of the numerous existing social groups. From a perspective of complementarity and expansion of “looks”, the permanent call for studies and publications analyzing the “politics of” and “policies on” health is equally important, adopting a national and comparative perspective in the production of evidence about the effects of policies on the health and well-being of populations ¹³.

The scientific publication that expresses reflections and results of studies with methodological rigor, multiple references ¹⁴, transdisciplinary character ¹⁵ and, especially, committed to antiracism, overcoming inequities, stigmas and prejudices that affect the health of the Brazilian population, is necessary to provide information and formulate policies, allocate resources, guide training and continuing education in health aimed at ensuring quality care in a universal public health system. More than ever, we reiterate our commitment to reaffirm the project of a “comprehensive PHC” ⁵, as desired since Alma-Ata ¹⁶, of which successes, incompleteness and challenges can be permanently the target of public, critical and democratic debate.

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• ¹
  Mendonça MHM, Vasconcellos MM, Viana ALd'A. Atenção primária à saúde no Brasil. Cad Saúde Pública 2008; 24 Suppl 1:S4.
• ²
  Conill EM. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cad Saúde Pública 2008; 24 Suppl 1:S7-16.
• ³
  Campos GWS. Suficiências e insuficiências da política para a Atenção Básica no Brasil: debate. Cad Saúde Pública 2008; 24 Suppl 1:S17-19.
• ⁴
  Sampaio LFR. Debate sobre o artigo de Conill. Cad Saúde Pública 2008; 24 Suppl 1:S19-21.
• ⁵
  Giovanella L. Atenção Primária à Saúde seletiva ou abrangente? Cad Saúde Pública 2008; 24 Suppl 1:S21-3.
• ⁶
  Cohn A. Os princípios do Sistema Único de Saúde e a Atenção Básica (Programa Saúde da Família): o perigo mora ao lado. Cad Saúde Pública 2008; 24 Suppl 1:S23-4.
• ⁷
  Gervás J. Atención Primaria, de la teoría a la práctica. Cad Saúde Pública 2008; 24 Suppl 1:S24-6.
• ⁸
  Conill EM. A autora responde. Cad Saúde Pública 2008; 24 Suppl 1:S26-7.
• ⁹
  Morosini MVGC, Fonseca AF. Revisão da Política Nacional de Atenção Básica numa hora dessas? Cad Saúde Pública 2017; 33:e00206316.
• ¹⁰
  Mendes A, Melo MA, Carnut L. Análise crítica sobre a implantação do novo modelo de alocação dos recursos federais para atenção primária à saúde: operacionalismo e improvisos. Cad Saúde Pública 2022; 38:e00164621.
• ¹¹
  Almeida PF, Giovanella L. Avaliação em Atenção Básica à Saúde no Brasil: mapeamento e análise das pesquisas realizadas e/ou financiadas pelo Ministério da Saúde entre os anos de 2000 e 2006. Cad Saúde Pública 2008; 24:1727-42.
• ¹²
  Dardot P, Laval C. A nova razão do mundo: ensaio sobre a sociedade neoliberal. São Paulo: Boitempo; 2016.
• ¹³
  Esperidião MA. Análise política em saúde: síntese das abordagens teórico-metodológicas. Saúde Debate 2018; 42(n.spe. 2):341-60.
• ¹⁴
  Fagundes NC, Burnham TF. Transdisciplinaridade, multirreferencialidade e currículo. Revista da FACED 2001; (5):39-55.
• ¹⁵
  Almeida Filho N. Transdisciplinaridade e o paradigma pós-disciplinar na saúde. Saúde Soc 2005; 14:30-50.
• ¹⁶
  World Health Organization. Primary health care: now more than ever. Report 2008. Geneva: World Health Organization; 2008.

Publication Dates

• Publication in this collection
  08 Aug 2022
• Date of issue
  2022

History

• Received
  18 July 2022
• Accepted
  18 July 2022