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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.25 no.12 Rio de Janeiro Dec. 2020  Epub Dec 04, 2020

https://doi.org/10.1590/1413-812320202512.23342020 

ARTICLE

Primary health care in the 25 years of Journal Ciência & Saúde Coletiva

Aylene Bousquat1 
http://orcid.org/0000-0003-2701-1570

Maria Guadalupe Medina2 
http://orcid.org/0000-0001-7283-2947

Maria Helena Magalhães de Mendonça3 
http://orcid.org/0000-0002-3917-9103

Patty Fidelis de Almeida4 
http://orcid.org/0000-0003-1676-3574

Rosana Aquino2 
http://orcid.org/0000-0003-3906-5170

Alaneir de Fátima dos Santos5 
http://orcid.org/0000-0002-7674-0449

Ligia Giovanella3 
http://orcid.org/0000-0002-6522-545X

1Faculdade Saúde Pública, Universidade de São Paulo. Av. Dr. Arnaldo 715, Cerqueira Cesar. 01246-904 São Paulo SP Brasil. aylenebousquat@usp.br

2Instituto de Saúde Coletiva, Universidade Federal da Bahia. Salvador BA Brasil.

3Escola Nacional de Saúde Pública Sergio Arouca, Fiocruz. Rio de Janeiro RJ Brasil.

4Instituto de Saúde Coletiva, Universidade Federal Fluminense. Niterói RJ Brasil.

5Faculdade de Medicina, Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil.


Abstract

Primary Health Care (PHC) is an area of study that has improved remarkably in the last decades. In Brazil, this academic production is highly expressed in the field of Collective Health. This paper aims to analyze the PHC production published in the first 25 years of the “Journal Ciência & Saúde Coletiva” (C&SC). A narrative review was carried out, with analysis of the themes, methods, scale of analysis, partnerships, and authorship. A total of 295 papers were published, which corresponds to 5.9% of the total publications. A growing trend in papers addressing PHC was observed. The studies were mostly empirical (78.6%), with a qualitative approach (58.0%) and were predominantly local or municipal. Studies on health professionals were more frequent. The three prevailing themes were the health care model, PHC performance or effectiveness, and the work process. The profile found dialogues with the rich and diverse experience of Brazilian PHC. However, the incorporation of broader analyses is still challenging. The published papers highlighted the debates and contributed to the reflection and dissemination of the experience of Brazilian PHC, which was and is central to the construction of the Brazilian Health System.

Key words: Primary Health Care; Bibliometrics; Periodicals as topic

Resumo

A Atenção Primária à Saúde (APS) é uma área de estudo que tem crescido nacional e internacionalmente. No Brasil, esta produção se expressa sobremaneira no campo da Saúde Coletiva. O objetivo do artigo é o de analisar a produção sobre APS divulgada nos primeiros 25 anos da Revista Ciência & Saúde Coletiva (C&SC). Foi realizada uma revisão narrativa, com análise dos temas, dos métodos, da escala de análise, das parcerias estabelecidas e da autoria. Foram publicados 295 artigos, o que corresponde a 5,9% do total de publicações. Observou-se tendência de crescimento de artigos versando sobre a APS. Os estudos foram na sua maioria empíricos (78,6%), com abordagem qualitativa (58,0%) e com predomínio de abrangência local ou municipal. Quanto à população estudada, foram mais frequentes os estudos realizados com profissionais de saúde. Os três temas que predominaram foram: o modelo assistencial, o desempenho ou efetividade da APS e o processo de trabalho. O perfil encontrado dialoga com a rica e diversa experiência da APS brasileira, no entanto permanece o desafio de incorporar análises mais amplas. Os artigos publicados evidenciaram os debates e contribuíram para a reflexão e a divulgação da experiência da APS brasileira, que foi e é central para a construção do Sistema Único de Saúde.

Palavras-chave: Atenção primária à saúde; Bibliometria; Publicações periódicas como assunto

Introduction

The first 25 years of the Journal Ciência & Saúde Coletiva (C&SC), edited by the Brazilian Association of Collective Health (Abrasco), are contemporary to the process of building the Brazilian Unified Health System (SUS). The C&SC pages reflected many of the debates, disputes, questions, achievements, and setbacks of this period1.

Undoubtedly, the establishment and implementation of the SUS produced essential changes in the distribution of political power and responsibilities among the spheres of government (national, state and municipal), between the State and civil society through new mechanisms of social participation and necessary decentralization process, with the transfer of decision-making power and competences from national to subnational levels. Another central point in the SUS construction was the definition of the care model and the role of Primary Health Care (PHC) in this model2,3.

The SUS design was influenced by several proposals for health care models with different rationales and previous local experiences, which have shaped new approaches in PHC and care models always in a dispute over the first three decades, driven by national policies, including relevant political, managerial and organizational changes3,4. Disputes over the SUS care model permeated the critical expansion of primary care services and the Family Health Strategy (ESF) over more than 20 years, founded on different conceptions of the right to health and the organization of professional practices and inclusions: between universal access and focused care, between emergency and comprehensive care, response to group and individual needs, self-referred and scheduled demand, among others4.

What Viana and Dal Poz (2005) have labeled as “program void” since the creation of the SUS5 begins to fill in, in the 1990s, a model to reorient care practice, consistent with the principles of universality, comprehensiveness, and equity with the Family Health Program (PSF). While initially conceived as focused programs, PACS (1991) and PSF (1994) targeted population groups without access and with a selective scope of actions, promoted innovative reorientation of the care model in the SUS, combining the individual care practice with the population approach from the perspective of territorialized health surveillance2,4,6. Over time, elements found in several models, such as program actions to priority groups, reorganization of the self-referred demand with user-centered reception, and multidisciplinary support, were incorporated into the PSF now called the Family Health Strategy (ESF)7,8.

From the 2000s, PHC’s attributes synthesized by Starfield9 (first contact, scope/comprehensiveness, longitudinality/relationship and coordination, family orientation, community orientation, and cultural competence) started to be disseminated in publications nationwide. They were incorporated into the National Primary Health Care Policy (PNAB) 20064. Moreover, efforts to evaluate PHC services began to be induced by the Ministry of Health (MS) through PHC assessment institutionalization initiatives in the SUS10.

In 2011, PNAB underwent the first review, which revised the concept of PHC and incorporated actions developed by new devices, such as the Family Health Support Center (NASF), created in 2008, from the perspective of interprofessionality, multidisciplinary support, continuing education, shared clinical responsibility for a higher care resolution, and the financing of different modalities of EFS teams. In the same decade, policies for improving the physical infrastructure of the PHC units (UBS) (Requalifica), access and quality (PMAQ-AB), and providing doctors (PMM) stood out, all historical problems for the sustainability and expansion of PHC.

It is worth mentioning that, as of 2017, increasingly intense political conflicts, which are expressed both in attacks on democracy and in setbacks for the advances obtained by the implementation and expansion of a community-based PHC care model, materialized in the latest review of the PNAB and several subsequent PHC-related policies11,12.

These advances and setbacks are expected to have repercussions on the content of publications in the C&SC. After all, one of the outstanding characteristics of Public Health is to be a field that articulates knowledge and practice. Moreover, unlike other countries, one of Brazilian PHC’s features is its proximal interface with Public Health, its critical territorialized approach and the presence of multiprofessional teams. In this scenario, this paper aims to analyze the path of the PHC knowledge production disseminated in the first 25 years in the Journal C&SC. It is assumed that this production is related to changes in national and local health policies and processes to promote research and institutionalize evaluation initiatives over the period.

Material and methods

A narrative review of the PHC production published in the Journal C&SC from 1996 to 2019 was carried out. The search for papers was performed on the SciELO platform, which makes available all papers published in the period. Initially, we included works that contained the following keywords in any of the search indexes: “Primary Care”, “Basic Care”, “Family Health”, “Community Health Worker”, “Family Health Strategy”, and “Family Health Program”. Then, the selection was expanded with the inclusion of papers with the following keywords: “Reception”, “Home Care”, “Primary Health Care”, “More Doctors Program”, and “Basic Health Services”. The last step was accessing all thematic issues addressing PHC, identifying possible losses from previous strategies. These numbers were identified on C&SC’s website, which provides all published issues.

The initial search identified 367 papers. Each abstract was read separately by two researchers who had been studying PHC for at least 20 years. Papers that addressed a topic relevant to the PHC scope were selected, and any disagreement was resolved by a third researcher who made a new assessment. In this process, 72 works were excluded, and the 295 papers included were analyzed and classified.

The theme and sub-theme addressed, the methods used, the type of paper, the scale of analysis, the institutional partnerships established, the language of publication, and the authorship profile were analyzed for each of the selected works. An Excel database was prepared with the primary bibliographic data for all included papers. This spreadsheet was exported and analyzed using the IBM SPSS Statistics version 23 program. The main themes addressed in the papers were grouped into the following categories: policy analysis; financing, costs and application of resources; care model; articulation of PHC in health care networks; health management; work process; work management; training and continuing education; access, accessibility, coverage, and use of services; PHC performance or effectiveness; user profile; perception of illness and care processes; health promotion; family; health education; reform of other health systems. The definitions adopted are presented in Chart 1.

Chart 1 Details of the criteria for the classification of papers per theme, Journal Ciência & Saúde Coletiva, 1996-2019. 

Theme Details
Care model Approach to aspects related to technological arrangements for the provision of care in PHC; establishing relations between services; in articulating PHC with other sectors and multidisciplinary support. Analysis of PHC attributes, such as comprehensiveness, longitudinality and family and community orientation, were also included.
PHC performance or effectiveness Analysis of process or result indicators, including user satisfaction, to assess the degree of implementation of PHC actions or the quality of the teams' work performance or their effectiveness.
Work process Characteristics of health practices, their organization, and the attributions and role of professionals working in PHC.
Health management Approach to the capacity of government, profile, competencies, and health managers' practices and use of management technologies, including social participation.
Training and Continuing Education Issues related to training and continuing education for team professionals, including profile assessment and skills analysis, and appreciation of specialization courses and professional master's degrees.
Policy analysis Analysis of the formulation or implementation of the PHC policy, as a whole, or one of its components.
Access, accessibility, coverage, and use of services Evaluation of access, accessibility, coverage, and use of services, whether from the perspective of users or professionals and managers or through health indicators.
Reform of other health systems Analysis of health system reforms with a focus on PHC in other countries.
PHC articulation in health care networks Articulation of PHC with other levels of the health service system, lines of care, and construction of care networks.
Perception of illness and care processes Perception of health professionals and users about the health-disease and care processes and the social representations in the health-disease process.
Users’ profile Characterization of the profile of PHC users.
Health promotion Approach to actions, proposals, and programs related to health promotion within PHC.
Work management Forms of management of the work process, labor division, and communication, insertion, and remuneration policy, and turnover of PHC professionals and PHC workers' health surveillance actions.
Financing, costs, and application of resources PHC financing, costs of actions and services, financial incentives, and application of resources for health actions.
Health Education Analysis of educational practices, including the representations of health professionals about these practices.
Family Conceptions and reflections on the family and discussing instruments for its approach.

The “subthemes” of the papers were also identified, considering specific approaches to the theme as subthemes, notably regarding problems, program area, and professional or political category. For example, a study on user accessibility in the context of the More Doctors Program (PMM) was classified in the theme “access, accessibility, coverage and use of services” and in the subtheme as “More Doctors Program”; a paper that addressed the oral health professionals’ work process was classified under “work process”, with subtopic “oral health”. All papers were classified by theme, but only those that highlighted any specific focus in their abstracts were classified under the subtheme.

Regarding methodological aspects, the first categorization was related to the type of approach - quantitative or qualitative. Then, the 295 papers were classified as empirical, using primary or secondary data; or theoretical-conceptual, which corresponded to a set of productions - essays, debates, opinions and reviews - characterized by the expression of value judgments or viewpoints on PHC, although in some cases, empirical evidence was used. In a third step, the scope of the study was identified only for the empirical papers (n = 232) - local, municipal/district, regional, state, large regions/national, international - and the subjects involved in data production - users, professionals, administrators/managers, health councils/social participation, others and does not apply (papers based on secondary data and documents).

The institution and country of the first author, the total number of authors and the number of institutions involved were considered, and whether institutions located in more than one state of the federation or country were included in order to characterize authorship and institutional partnerships. Disseminating languages have also been listed.

The number of papers listed was compared to the total number of papers published in the Journal C&SC, which were manually retrieved from the journal’s page on SciELO, considering all works published in all the journal’s sections.

Results

The 295 papers that looked at PHC in the Journal C&SC were analyzed, which corresponded to 5.9% of the journal’s total publications between 1996 and 2019. The absolute number varied over the years, but an increasing trend line of PHC production at C&SC was observed (Figure 1) despite the variation, which partly results from the publication of eight PHC-related thematic issues in these first 25 years of C&SC, with 107 papers published in the thematic issues. It is worth mentioning that the first work on the topic was published only in 2002.

*Years with thematic numbers addressing PHC

Figure 1 PHC papers published in C&SC and main evaluative frameworks, 1996-2019. 

The special issues concentrated 36.3% (n = 107) of all production on PHC. The topics covered were evaluation as a change strategy; multi-professionality in the then Family Health Program; Primary Care in the care of diseases and conditions; Family Health expansion and challenges; PHC and family health; PHC reform in the city of Rio de Janeiro; the More Doctors Program; and, finally, a comparative analysis of PHC in the cities of Lisbon and Rio de Janeiro.

The mean number of authors per paper was 3.9, with a median of 3 and a standard deviation of 2.1. As for the language, only 10 works (3.4%) were published exclusively in a language other than Portuguese. A growing bilingual number of publications was observed, especially in the last five years, with 29.8% of publications also being published in English and only six papers in Spanish.

Considering the institutions of first authors, the journal published mainly Brazilian authors (93.6%), followed by Portuguese (3.7%), and most of them were women (63.7%). Among Brazilians, the authors originated predominantly from institutions in Rio de Janeiro (18.0%), São Paulo (17.6%), Federal District (9.5%), Minas Gerais (9.2%), Rio Grande do Sul (8.5%). No first authors from institutions in Acre, Roraima, Rondônia, Amapá, Sergipe were identified, and only two works were related to the state of Amazonas and one to the state of Pará.

Although most studies have been carried out by researchers from more than one institution (59.0%), in only 24.1% of these, this collaboration covered different states of the federation (Table 1).

Table 1 Characteristics of PHC papers published in C&SC from 1996 to 2019. 

Characteristics No. %
Approach (n = 295) Qualitative 171 58.0
Quantitative 106 35.9
Qualitative/quantitative 18 6.1
Type of Study (n = 295) Empirical 232 78.6
Essay, Debate, and Opinion 55 18.6
Review 8 2.7
Scope of Empirical Studies (n = 232) Local (UBS) 47 20.3
Municipalities/Districts 111 47.8
Region 15 6.5
State 19 8.2
Large Regions/National 26 11.2
International 15 6
Subjects (n = 232) Professionals 77 33.2
Users 40 17.2
Managers 22 9.5
Professionals and managers 15 6.5
User, professional and manager 10 4.3
User and professional 8 3.4
Other 4 1.8
Unspecified 56 24.1
Institutions involved (n = 295) One 121 41.0
Two or more 174 59.0
Federated Units One 220 74.6
Two or more 71 24.1
Unspecified 4 1.3

Source: Elaborated by the authors.

Most studies used a qualitative approach (58.0%). Empirical studies were predominant (78.6%), although a vital percentage was characterized as theoretical-conceptual papers that included essays, debates, reviews, and opinion papers. The scope of most of the empirical papers (68.1%) was local and municipal/district-related. Few were national (11.2%), in general, resulting from evaluation processes induced by the Ministry of Health, such as PROESF and Self-assessment for the Improvement of Access and Quality of Primary Care (AMAQ), besides studies using the approach of Primary Care-Sensitive Hospitalizations (PSCH) and Primary Care Assessment Tool (PCATool) (Table 1).

As for the population studied, works on health professionals were more frequent, followed by users and managers. Approaches with more than one category were rarer (Table 1). Only three papers focused on health councils. Moreover, almost a quarter of the empirical studies used secondary data or documents as data sources, grouped as Unspecified (Table 1).

Concerning the thematic classification, three themes predominated, accounting together for more than 50% of the studies: care model (18.3%), PHC performance or effectiveness (17.0%), and work process (15.3%) (Table 2). If we add to the previous three the themes of “Access, accessibility, coverage, and use of services” (4.8%) and “Articulation of PHC in healthcare networks” (3.4%), we can see that the focus of researchers in almost 60% of the papers on PHC published in the journal were aspects related to the directionality and effectiveness of PHC change regarding the SUS construction process and the Brazilian Health Reform. The remaining 40% of the papers addressed several topics, and, in isolation, none reached a percentage equal to or greater than 10%: “Health management” (9.2%), “Training and Continuing Education” (7.5%), “Analysis of the Brazilian PHC policy” (5.8%), “Reform of other health systems” (4.1%), “Articulation of PHC in health care networks” (3.4%), “Perception of illness and care” (3.7%), and others, which did not reach 3% of the analyzed works (Table 2). Regarding the reform of other health systems globally, papers that analyzed PHC in Portugal, Germany, Chile, Paraguay, Uruguay, Argentina, and Spain and Latin America as a whole were published.

Table 2 Thematic classification of PHC papers published in C&SC, 1996 to 2019. 

Theme All Empirical and Reviews Essays, debates, and opinion
N % N % N %
Care model 54 18.3 40 16.7 14 25.5
PHC performance or effectiveness 50 17.0 49 20.4 1 1.8
Work process 45 15.3 36 15.0 9 16.4
Health management 27 9.2 22 9.2 5 9.1
Training and Continuing Education 22 7.5 20 8.3 2 3.6
Policy analysis 17 5.8 5 2.1 12 21.8
Access, coverage, and use 14 4.8 14 5.8 0 0.0
Reform of other health systems 12 4.1 8 3.3 4 7.3
PHC in Networks and Regions 10 3.4 8 3.3 2 3.6
Perception of illness and care 9 3.1 9 3.8 0 0.0
Users’ profile 8 2.7 7 2.9 1 1.8
Health promotion 8 2.7 6 2.5 2 3.6
Work management 7 2.4 7 2.9 0 0.0
Financing, costs, and application 6 2.0 5 2.1 1 1.8
Health education 4 1.4 4 1.7 0 0.0
Family 2 0.7 0 0.0 2 3.6
Total 295 100.0 240 100.0 55 100.0

Source: Elaborated by the authors.

Comparing the empirical or review papers with the group of papers that aggregated the essays, debates, and opinion papers, “Care model” and “Work process” remained as favored themes in both groups. Most works that addressed “PHC performance or effectiveness” were from the group of empirical or review papers, while “Policy analysis” in general was addressed in essays, debates, or opinion papers.

A specific sub-theme was identified for 227 papers, grouped in Table 3 according to certain similarities concerning focus. We observed that about 30% of the works focused on some PHC program area, emphasizing Oral Health (7.9% of the total and more than 25% of the papers in this subgroup).

Table 3 Distribution of papers published in C&SC by subtheme from 1996 to 2019. 

Subtheme N %
Health professionals 38 16.7
Community Health Workers 19 8.4
Other professionals 19 8.4
Mais Médicos (More Doctors) Program 18 7.9
Work process aspects 9 4.0
Interdisciplinary team and teamwork 6 2.6
Other (care practices, light technologies, and professional turnover) 4 1.8
Specialization and Master 3 1.3
Contracting and other forms of work management 5 2.2
Incentive programs 5 2.2
Health disorders and problems 22 9.7
Chronic diseases 8 3.5
PCSH 6 2.6
Other (Tobacco control, dengue, tuberculosis, people with disabilities, Down syndrome, violence) 8 3.5
Program areas 68 30.0
Oral Health 18 7.9
Child and Maternal and Child Health 12 5.3
Men’s Health 7 3.1
Elderly Health 7 3.1
Pharmaceutical care 6 2.6
Integrative and Complementary Practices 5 2.2
Others 13 5.7
Care model approaches 24 10.6
Health Surveillance and social participation 8 3.5
Multidisciplinary support 7 3.1
Other 9 4.0
Evaluation, Monitoring and Information Systems and Technologies 10 4.4
International health 12 5.3
Portugal 5 2.2
Other countries 7 3.1
Other 12 5.3
Total 227 100

Source: Elaborated by the authors.

Another expressive subgroup in this analysis, with 16.7%, addressed aspects related to the team’s professionals, such as, for example, practices or continuing education processes. In half of the cases, the professional in question was the ACS. We could identify aspects related to the health care model as subthemes, such as health surveillance and social participation, multidisciplinary support, and PHC attributes, in about 10% of the papers. A significant number of works, corresponding to almost 10%, focused on health diseases and problems, especially chronic diseases (3.5% of the total papers). Finally, it is worth noting the high percentage that addressed the More Doctors Program (7.9%), which was the subject of a particular supplement. The other subthemes were widely dispersed, with percentages around or below 5%, indicating the full range of investigated aspects of PHC.

Discussion and considerations

This paper aimed to identify the scientific production on PHC published in the C&SC. Thus, while it dialogued with the Brazilian Collective Health field production on the subject, the results presented here are limited to works published in the C&SC. The volume found is in line with the results obtained by Medina et al.13, who identified an essential production on Brazilian PHC, reaching more than 860 papers from 1980 to 2016. While the selection criteria adopted were different from those used here, the authors identified that C&SC was the journal with the second highest circulation of production, behind Cadernos de Saúde Pública, in a total of 153 journals. In this scenario of high dispersion in the dissemination of knowledge about PHC, the number of works found here corroborates that C&SC was and is a journal central to the construction of knowledge about Brazilian PHC within the SUS.

The first paper on PHC in C&SC was published only in 2002, seven years after the onset of the journal, and about a decade after the onset of the PACS/PSF experience, coinciding with a higher ESF coverage in Brazil. The gap between practice and the dissemination of scientific production, especially empirically-based production, is not exclusive to C&SC, nor Brazilian production13,14. Hirschhorn et al.15 reinforce the urgent need to produce, with agility, research and new evidence to strengthen PHC in health systems. An increased production of works has been noted since the publication of the first paper, following the political priority given to Family Health, with all the challenges in this process16.

The number of papers published annually varied, which may reflect both investments in the evaluation processes implemented by the Ministry of Health and the publication of thematic issues. Despite this variation, we can affirm unequivocally that PHC is a relevant topic with increasing space in C&SC.

If, in general, increased production on PHC is noted in C&SC, this dissemination still reflects, on the one hand, a large concentration of first authors from the wealthiest states of the federation. On the other hand, the absence of authors from several states, and the almost inexistence of first authors from the north region is a significant aspect of the unequal production of knowledge. This picture also reflects somewhat the distribution of public health masters and doctoral courses.

The production on PHC at C&SC refers mainly to local experiences, through a qualitative approach, published in Portuguese. An “inward dialogue” is observed, perhaps influenced, among other aspects, by the decentralized Brazilian health system model, whose financial onlendings from the central level to the municipalities, and the attribution of implementation responsibilities to the local entity, produced a mosaic of PHC experiences, portrayed by academic production in the area. While this is a characteristic of the rich and diverse Brazilian PHC, the challenge remains to make scientific production further recognized and debated internationally. Indeed, the dissemination in more than one language will contribute to this end.

Another aspect that cannot be overlooked when analyzing PHC production is the strong influence of federal policies for institutionalizing PHC monitoring and evaluation by federal management. A turning point was the creation of the Primary Care Monitoring and Evaluation Coordination Office at DAB/SAS/MS17 in 2003. Initiatives were also developed by the Department of Science and Technology (DECIT) of the Department of Science, Technology and Strategic Supplies/MS and joint public notices with the National Council for Scientific and Technological Development (CNPq), besides support for state research promotion agencies in the Research for SUS Program, which may justify the increased dissemination of production on the theme in the C&SC.

The Ministry of Health’s strategy of including universities as partners in the evaluation processes undoubtedly contributed to the growth of scientific production on the subject. This strategy was initially financed to research evaluation with sparse requests from academic institutions. It evolved in 2005 to the Expansion and Consolidation Project of the Family Health Strategy (PROESF) which promoted a set of baseline evaluative studies, encompassing 227 municipalities with a population over 100,000 inhabitants, which boosted evaluative research in primary care, especially with the use of cross-sectional design, combination of methods and case study by intentional sampling, and approach to managers, professionals, and users. These studies were present in the C&SC18-20.

On the other hand, another significant evaluative movement in the PHC scenario, namely, the Program for the Improvement of Access and Quality of Primary Care (PMAQ-AB), has not been reflected significantly in the production of PHC the Journal C&SC.

The studies from the PMAQ-AB published in the various journals were, in general, supported by cross-sectional designs with PHC professionals and users, combining mixed-methods (qualitative-quantitative) approaches, and different research techniques that allowed valuing the perception of its implementers and beneficiary citizens regarding the problems of care concerning structure, processes, and satisfaction of health needs21. In the C&SC, the papers relying on the PMAQ-AB databases of the first two evaluation cycles worked on new hypotheses when associated with other programs, such as the PMM or the effectiveness of family health training for comprehensive care in the ESF22,23.

In 2013, the More Doctors Program (PMM) produced an inflection in the national primary care policy, bringing to light the immense hardships in providing services in remote and more vulnerable areas24, In a short span, such policy generated an expressive set of publications, and the special issue of C&SC on the PMM produced in 2016 was considered the primary vehicle for the dissemination of opinion papers and debate on the PMM, and empirical papers with research results25.

The set of C&SC production is still focused on the national dimension, with several empirical studies analyzing the implementation of structural policies geared to strengthening PHC such as PROESF, PMAQ and, PMM, and or theoretical, review, or essay studies that capture the trend of the PHC structuring process in the country. However, analysis on a national scale, based on the data produced by these processes, is negligible, especially when taking as a parameter the full availability of the dataset related to the Brazilian PHC situation26. The low dissemination of these studies contrasts with the Brazilian PHC structuring process, which has consolidated a national care model in recent decades, with the establishment of practices, regulations, innovations, and reflections arising from the different national management practices, with intense dialogue between the governmental levels, which sets up the rich Brazilian experience in PHC in renewing the management and care models due to the health decentralization process.

The significant presence of empirical works with municipal or local scope, close to 70% of the studies, was also found in other reviews13,27-29. On the one hand, this result is associated with municipalities spearheading innovative experiences, which are frequently set as study objects, but also shows a mismatch between scientific production in PHC and the broad national PHC program - mostly qualitative studies, focused on few research groups, with elaboration hardly shared with other groups.

As for the themes, the predominance of analyses on the “PHC care model, performance or effectiveness” and “work process” reveals the researchers’ concern in analyzing the expected changes regarding the process of implementing the Brazilian PHC model, by means of the reorientation of care practices and their organizational rationale, and its results concerning population health indicators. In the first case, the results aim to contribute to the knowledge of aspects related to the technological arrangements of PHC care organization, including devices such as multidisciplinary support to teams and highlighting the investigation of the main PHC attributes, such as comprehensiveness, longitudinality and family and community orientation.

The debate around the health care model is central to the process of building the SUS, which is the cause of a movement in favor of international health systems reforms and expresses disputes between the so called biomedical model versus alternative models, shifting the object centrality and the service organization from the disease-hospital binomial to the individual-family-community-territory of health promotion and care production30,31. While highlighted as a specific theme, the PHC policy shows a given cross-sectionality and interface with other themes presented in the papers such as “work process”, “articulation of PHC in health care networks”, and is addressed in several studies that focus on overall policy analysis.

The analysis of PHC’s effectiveness in the organization of services and the health of the population has been gaining space in national and international literature26,32,33 since PHC is a favorable scenario to induce significant changes in individual and community illness standards. This is because PHC can promote the incorporation of new health promotion and disease prevention practices, expand accessibility to PHC actions and services, and other levels of complexity of the health system, by imprinting new organizational dynamics in health units. Concerning the third most discussed topic, namely, the work process, the authors further discussed professionals’ practices and their attributions and reflected upon the role of several health categories, especially the community health worker. The ACS highlight reveals its relevance in constructing the Brazilian PHC model, as underscored by several authors34-36.

The papers that addressed health management, highlighting the profile, competencies, and practices of managers, including the use of technologies, and those that discussed the various training and continuing education initiatives of health professionals, show their concern with the necessary qualification of PHC to fulfill its essential functions. Noteworthy is the low presence of other relevant themes, such as the articulation of PHC in the care network, work management, financing, health promotion, health education and reflections on the family - critical knowledge gaps deserving further analysis, and which represent obstacles to be overcome by the Brazilian PHC.

Undoubtedly, the pages published in the first 25 years of C&SC highlighted the debates and contributed to the reflection and dissemination of the rich experience of Brazilian PHC. A special issue on Alma Ata’s 40 years was published in 2020, keeping with this important tradition, and we invite readers to visit it37. The set of production on PHC in these 25 years provides central reflections for the consolidation of the project of an equitable and comprehensive Brazilian health system: our SUS. Indeed, future C&SC pages will continue to disseminate these experiences and debates.

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Received: July 01, 2020; Accepted: July 02, 2020; Published: July 04, 2020

Collaborations

A Bousquat, MG Medina, MHM Mendonça, PF Almeida, R Aquino, AF Santos and L Giovanella participated equally in all stages of preparation of the article.

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