Laboratory for innovation in Primary Health Care: implementation and results

Abstract

This article presents and problematizes innovation actions aimed at improving the quality of Primary Health Care (PHC), describing an experience that can be adapted to different contexts, considering diverse sociodemographic, economic, cultural and epidemiological realities. We conducted an exploratory study using documentary sources referring to the implementation of the Campo Grande Laboratory for Innovation in Primary Health Care (INOVAAPS). The project proposes the reorientation of the care model adopted in the municipality’s public primary care services, redefining work processes and improving the quality of practice. We identified product, process and organizational innovations that have the potential to transform and tailor health care practices to the population’s health needs. It is concluded that the proposals implemented by the project focus on the consolidation and expansion of access to primary care, recruitment and training of adequately qualified health professionals, adoption of resolutive technologies, regulatory improvement, and strengthening the mediating role of primary health care.

Key words
Innovation; Primary Health Care; Family Health Strategy; Unified Health System; Brazil

Resumo

O objetivo do estudo foi apresentar e problematizar as ações de inovação para a qualificação da Atenção Primária à Saúde (APS), evidenciando experiência que pode ser adaptada e implementada em diversos contextos, considerando as diferentes realidades sociodemográficas, econômicas, culturais e epidemiológicas. Trata-se de um estudo exploratório realizado a partir de fontes documentais sobre a implementação do Laboratório de Inovação na Atenção Primária à Saúde (INOVAAPS) no município de Campo Grande-MS, que propõe a reorientação do modelo assistencial, com ressignificação dos processos de trabalho na APS, qualificando as práticas. Foram identificadas ações inovadoras organizacionais, processuais e de produto que são potentes para a transformação e readequação de práticas do fazer em saúde. Concluiu-se que as propostas já executadas estão pautadas na expansão, consolidação e ampliação de acesso à APS, à provisão e formação profissionais adequadas, à alocação de tecnologias resolutivas, ao aprimoramento da regulação e à efetivação do papel mediador da APS.

Palavras-chave
Inovação; Atenção Primária à Saúde; Estratégia Saúde da Família; Sistema Único de Saúde; Brasil

Introduction

Innovation is the creation of new realities, to make something exist or give new meaning to something that already exists. Innovation can be stimulated, promoted and managed, gaining force in the application of knowledge and practices in the area of health¹, as well as other sectors of the economy, such as government services². The analysis of organizational innovation has multiple benefits³. Including primary health care (PHC) in this analysis can therefore help to overcome challenges and implement changes to address gaps in a key sector of Brazil’s national health service, the Unified Health System (SUS, acronym in Portuguese).

The overriding PHC model in Brazil is the Family Health Strategy (FHS), which has received significant investment aimed at expanding population coverage for health care and reorganizing and improving the quality of primary care services⁴.

Despite ongoing efforts and clear advances in the expansion of coverage⁵, important gaps exist in the organization and management of the SUS, including underfunding⁶, lack of basic equipment, variation in the profile of health professionals, barriers to the coordination of care, the existence of different management models⁷, and problems related to infrastructure, supplies and the qualification of health workers⁸. These problems are aggravated by socioeconomic differences and health inequalities/inequities.

One of the factors influencing quality of care is the qualification health professionals for PHC⁹. Evidence shows that family and community health training during residency and specialist training have a positive impact on health indicators, resulting in lower rates of hospitalization for ambulatory care sensitive conditions^5,10, an increase in the registration and follow-up of patients with diabetes and high blood pressure⁵, improvements in maternal and infant care and health indicators¹¹, and stronger primary care orientation¹².

The challenges mentioned above demand capacity for continuous innovation in the formulation and implementation of public policies and care practices in the SUS. To this end, investment is needed in professional training, information and communications technologies^13,14, and to improve working conditions and team dynamics, putting patients at the center of health care⁴.

The innovation process should begin with the concept of innovation as a response of the organization to the pressures of the environment in which it exists³. Based on this concept, the Laboratory for Innovation in Primary Health Care (INOVAAPS) was created in Campo Grande, the capital of Mato Grosso do Sul, to support practical science-based actions aimed at strengthening PHC in the city’s public health services, primarily through innovation in care technologies, management and communications.

In the face of a political and economic climate marked by fiscal austerity, undermining the principle of universal access, and the pressing need to strengthen PHC as the cornerstone of the SUS⁴, studies investigating innovation in PHC are essential to promote changes in service delivery and improvements in health policy, working towards the ultimate goal of improving health care³.

INOVAAPS can be adapted to various contexts, considering different sociodemographic, economic, cultural and epidemiological realities. The aim of this study was to present and problematize the actions developed by the laboratory, highlighting the role this innovative strategy plays in improving the quality of PHC.

Method

This article comprises an experience report that draws on documentary sources covering the implementation of INOVAAPS in Campo Grande between March and October 2020. The original data is problematized to allow readers to associate what was planned and implemented in this municipality with other contexts, offering innovative alternatives that can inspire other actions in different realities.

We used the following documents produced up to October 2020 discussing innovation actions developed by INOVAAPS since the beginning of the project: a. the INOVAAPS project; b. management reports; c. presentations and debates from the I INOVAAPS Campo Grande Seminar, held in September 2020; and d. documents available on the INOVAAPS platform¹⁵.

The data were organized and presented to show the project’s goals and objectives and the participating health centers and PHC teams. The goals, core actions and results were then analyzed in relation to the recommendations for strengthening PHC in Brazil proposed by Tasca et al.⁴.

Results

INOVAAPS Campo Grande was initiated in 2020. The city has a population of 895,982 inhabitants, representing around 32% the state population. With a population density of 104 inhabitants per sq. km, Campo Grande is the third largest and most developed urban center in the Center-West Region and Brazil’s 22nd largest city (IBGE, 2020)¹⁶.

The local health system is relatively well structured in line with the majority of Ministry of Health guidelines and policies. It is an important referral center within the state health care network (HCN), providing primary, specialized, urgent and emergency, and hospital care services. However, the system has a number of shortcomings related to the achievement of the attributes of primary care, professional training and coverage of the FHS.

Based on this observation, the Campo Grande City Council Health Department (SESAU, acronym in Portuguese) sought support from the Ministry of Health via the Oswaldo Cruz Foundation (FIOCRUZ) to plan and implement the changes necessary to address the above shortcomings. In July 2019, the three organizations signed a technical cooperation agreement aimed at supporting the development of strategic actions in the areas of PHC and health surveillance. The focus of these actions is institutional support, bringing together knowledge and experience to identify, analyze and develop interventions for essential PHC settings to improve resolvability and facilitate decision-making by health managers.

The project proposes a shift in the care model, redefining primary care work processes and improving the quality of practice and learning processes in everyday work, including residency programs. In this way, the project aims to produce knowledge and technologies that contribute to addressing the shortage of PHC professionals.

Figure 1 presents a flow diagram of the project’s core actions and overarching objective.

Figure 1
Project flow, actions and overarching objective.

Core goals were defined based on local demands, as shown in Chart 1.

Chart 1
Goals of the Laboratory for Innovation in Primary Health Care.

- To support the local health authority in decision-making processes - To restructure the Family and Community Health Residency Program - To structure the Interprofessional Family Health Residency Program - To build the capacity of primary care teams - To implement the Campo Grande Observatory on Primary Health Care to help family health teams manage the health region - To support health surveillance actions - To implement the telemedicine service and diagnostic support - To undertake evaluations of PHC using the PCAT - To conduct surveys with SUS workers

Source: Authors' elaboration

The settings for the implementation of the core actions comprise nine key primary care centers (PCCs) identified by SESAU to represent the diversity of the municipality’s seven health districts. The criteria used included shortcomings in the health region, extent of coverage of primary care teams and health region population density.

The nine participating PCCs and the number of existing teams in 2019 and number of new teams in 2020 in each center are shown in Table 1. As a result of the actions, coverage of the FHS increased from 52% before the project to 75% after the initiation of INOVAAPS.

Table 1
Participating Primary Care Centers, number of teams in 2019 and number of new teams after the initiation of the INOVAAPS project, Campo Grande-MS, 2020.

Center	N° FHTs in 2019	N° OHTs in 2019	New FHTs*	New OHTs**
FHC Oliveira	03	03	01	01
FHC Batistão	03	03	01	01
FHC Itamaracá	04	04	01	01
FHC Moreninha	04	04	02	-
FHC Parque do Sol	04	04	-	-
FHC Noroeste	04	04	-	-
FHC Vida Nova	03	03	-	-
FHC Coophavilla	04	06	06	04
FHC Tiradentes	04	08	08	06
Total	33	39	19	13

• ^*
  Family Health Teams;
• ^**
  Oral Health Teams.
Source: Authors' elaboration.

The core goals, actions and results achieved by INOVAAPS up to October 2020 are presented in relation to the recommendations for strengthening PHC in Brazil proposed by Tasca et al.⁴ (Chart 2).

Chart 2
Core goals, actions and results of the Laboratory for Innovation in Primary Health Care and the recommendations for strengthening PHC in Brazil.

Recommendations (Tasca et al., 20204)	INOVAAPS goals	Actions and results
Provide health actions and services according to the needs of the population.	Support the local health authority in decision-making processes.	Creation of a PHC service portfolio. The service portfolio was implemented in all the municipality's PCCs. This measure was important for guiding PHC actions and included a strong emphasis on interprofessional clinical practice. The portfolio broadened the scope of PHC practices in line with Ministry of Health guidelines, leading to a reduction in referrals to specialized care and urgent services. It constitutes an important care management tool.
		Creation of the Patient Notebook to record and follow-up procedures and health services. The Patient Notebook acts as a passport to the health network, recording patient pathways through the municipality's HCN; it includes appointments and other patient health information and provides details of HCN and services.
Increase funding for PHC.		Review of terms of reference and contracts with service providers. The review showed that amounts paid to a major service provider had increased substantially while the number of procedures had decreased, meaning more was being paid for less services. The respective contracts were renegotiated and quantitative and qualitative targets were set, leading to a rise in the number of procedures and consequent increase in funding of R$7,368,817.97 and resources allocated to PHC. Coverage of the FHS increased from 52% to 75%. Adherence to ministerial orders increased, resulting in an increase in funding and expansion of access to health services.
Not applicable.		Legal and accounting guidance provided to support decision making.
Guarantee adequate physical infrastructure, technology and supplies, and a comfortable environment for the effective functioning of primary care centers.		Support for innovations and provision of equipment and supplies necessary for implementing proposed changes: residents' and preceptors' kits; student insurance, basic care kits for PCCs. The equipment and supplies enabled improvements in work processes. The kits included stethoscopes, sphygmomanometers, personal protective equipment, measuring tapes, flashlights, backpacks, squeezy bottles, flash drives, pulse oximeters, peak flow meters, fetal dopplers, vascular dopplers, glucometers, urine test strips, portable digital scales, digital thermometers, and otoscope kits with ophthalmoscopes. Books were also supplied to the library for training support. Mapping of the physical infrastructure of health centers, cost analysis of the necessary infrastructure improvements and development of budget worksheets for renovation planning. Development of architectural plans outlining the improvements to the physical infrastructure of health centers. Production of an Environment Manual for family health centers. Development of a standardized layout for PCCs in accordance with Ministry of Health guidelines. Improvements to health centers to comply with physical infrastructure standards and provide an adequate environment, understood as a social and professional space. For example, a common problem in the PCCs was the physical infrastructure of the pharmacies. Modifications were made to these areas to improve storage and customer service, thus strengthening pharmaceutical assistance and, consequently, patient care. Reorganization of the SESAU's stockroom, including layout modifications and standardization of work processes. Control of incoming and outgoing supplies and expiration date monitoring. These actions led to greater effectiveness in the allocation of supplies and resources and reduced waste.
Develop a regulatory system centered on PHC.		Reorganization of the work processes in the SESAU's regulatory system (SISREG) to integrate processes and PHC. PHC doctors are scheduling procedures and appointments in other services of the HCN, streamlining appointment scheduling, reducing queues and reducing inequities in access to health care.
Strengthen PHC professionals' care technology skills. Broaden the clinical-care role of the professional groups that make up PHC teams using interprofessional protocols based on the best available science.	Build the capacity of primary care teams.	Meetings with health teams attended by all professionals and residents; training activities, such as clinical meetings and seminars (face-to-face and virtual during the pandemic). The teams conducted a status appraisal of the health regions and their responsibilities. Actions to enhance welcoming; all health team professionals incorporated into regional health surveillance; implementation of pharmaceutical appointments. Procedures previously performed in specialized or urgent care services now performed in primary care services, for example: cantoplasty, ear lavage, IUD insertion, management of hypertensive crises. Increased PHC resolvability and reduced turnover. Reorganization of oral health team work processes, including: shared care between family and oral health teams; construction of an access flow diagram, considering clinical factors and social vulnerability and paying more attention to patients who need home visits/appointments; welcoming for all patients seeking dental treatment, including risk screening; participatory strategic planning; information analysis and management support for oral health teams - e-SUS and SISREG. Increase in the productivity of oral health teams, resulting in improved access to oral health services. Advances in the coordination of care and monitoring of therapeutic itineraries in different oral health services. INOVAAPS seminar; cycle of debates (thematic meetings between professionals); training across the entire municipal HCN (currently online due to the pandemic). Presentation and debate seven months after the initiation of INOVAAPS. Proposed actions include a review of work processes and team training.
Develop a PHC professional training plan	Restructure the Family and Community Health Residency Program.	Restructuring of the Family and Community Medicine Residency Program The program previously offered only a small number of annual positions, for which there was little demand. The restructuring of the program led to a considerable increase in the number of positions and qualified preceptors and differentiated resident remuneration. Increase in the number of PHC doctors (38 family and community medicine residents), resulting in a significant increase in coverage and scope of PHC practice. It is expected that by the end of the program residents will be qualified to perform PHC procedures and have a series of tools at their disposal, enabling them to resolve 90% of the population's health problems, including both acute and chronic conditions.
Develop a PHC professional training plan.	Structure the Interprofessional Family Health Residency Program.	Implementation of the Interprofessional Family Health Residency Program, offering a significant number of positions: 77 residents from 7 different professional groups employed in the municipality's PHC services. The interprofessional and family and community residency programs triggered the development of new work processes, including: territorialization; team welcoming; implementation of the electronic information system e-SUS AB; strengthening of nursing appointments; creation of a care hub and teleconsultation; reorganization of access to oral health care; pharmacological appointments; resumption of team meetings; improvements in the quality of clinical records in the electronic health records system; Patient Notebook; and rehabilitation after COVID-19.
Not applicable.	Support strategic health surveillance actions.	Contribution to the development of an action plan designed to integrate PHC and health surveillance. PHC and health surveillance integration and health promotion workshops. Support provided to regional offices to promote the integration of health surveillance actions into primary care by health surveillance specialists. Platform for the real-time analysis of data from the national notifiable diseases information system (SINAN), with feedback to family health teams or care centers.
Promote strategies to defend and strengthen PHC, including the generation of scientific knowledge and dissemination of successful innovative experiences.	Implement the Campo Grande Observatory on Primary Health Care to help family health teams manage the health region.	Implementation of the Campo Grande Observatory for Information and Communications Technology in Health Systems and Services (OTICS-Campo Grande). Creation of an open-access platform providing comprehensive information about INOVAAPS and project actions, documents, reports, manuals, protocols, activities schedule, among others. The platform has a "Where to get care" resource, through which patients can obtain the address, contact details and opening times of their referral center (https://labinovaapsfiocruz.com.br/portal/#/). All materials from the seminars are available on the platform.
Promote the mediating role of PHC.		Selection and training of 7 supporters (1 per health district) to develop actions to promote the integration of PHC and health surveillance. Monitoring of health indicators. Guidance and support provided to health districts.
Broaden forms of access to PHC.	Implement the telemedicine service and diagnostic support.	Implementation of Teleconsultation and Teleinfectology services during the COVID-19 pandemic. The Teleconsultation service offers patients the opportunity to book telephone appointments. The Teleinfectology services was implemented to offer clinical support provided by infectologists to health professionals across the country during the COVID-19 pandemic.
Promote strategies to defend and strengthen PHC, including the generation of scientific knowledge and dissemination of successful innovative experiences.	Undertake evaluations of PHC using the PCAT.	Study titled "Presence and extent of primary care attributes based on the experiences of adult users of public primary care services in Campo Grande, Mato Grosso do Sul". The aim of the study was to verify the strength of primary care orientation in the municipality's primary care services. First phase of the study concluded. The findings show that essential and general scores were below 6.6. Family health clinics achieved better scores than family care centers. The findings show that there is still a way to go to achieve strong primary care orientation in the municipality's PHC services.
	Conduct surveys of SUS workers.	Survey of SUS workers in Campo Grande. The survey investigated health professionals' perceptions of the factors influencing their performance and motivation. The findings showed a number of key issues that need to be addressed, including improving the workplace environment, communication, transparency and work processes.
Broaden the clinical-care role of the professional groups that make up PHC teams using interprofessional protocols based on the best available science. Strengthen PHC professionals' care technology skills.	Support the local health authority in decision-making processes. Support strategic health surveillance actions.	Creation of a Care Hub for suspected cases of COVID-19. Development of a proposal to maintain patient affiliation during the pandemic: organization or maintenance of user registration; definition of vulnerable service users; special attention to mental health; remote contacting of service users. Definition of a separate area for seeing suspected cases of COVID-19. Implementation of World Health Organization recommendations on patient management during the COVID-19 pandemic.

• SESAU=Campo Grande City Council Health Department; HCN=Health Care Network; SISREG=Position Regulation System. PHC=Primary Health Care.
Source: Authors' elaboration.

A number of challenges were faced during the implementation of the innovation actions proposed by INOVAAPS, including relational, organizational and structural barriers that are common in processes of change. The following problems are worth highlighting: resistance of some managers and PHC professionals to change; disagreements between actors involved in the processes; difficulties in coordinating PHC with other services in the HCN; significant number of incomplete spreadsheets; excessive meetings; inconsistencies in user registration; difficulties in implementing the service portfolio and incorporating procedures not previously adopted in the municipality’s PHC services; difficulties related to training-service integration and the incorporation of residents into PHC teams; low resolvability rates in more complex cases; teamwork problems; and inadequate physical infrastructure and care center environments.

To overcome these obstacles, the project team focuses its efforts on the following: negotiation; frequent training and capacity building in diverse areas; encouraging teams to play an active role in promoting patient-centered care; developing viable alternatives for problem solving; reorganizing and optimizing the SISREG; the role of supporters; providing care management technologies and tools; matrix support; actions that bring together and promote interaction between family health, oral care and health surveillance teams and between PHC and other services across the HCN; strengthening management committees; and improving the physical infrastructure and environment of care settings. It is also important to stress that the actions described in Chart 2 also contribute to overcoming these challenges.

Discussion

The findings of this study demonstrate the importance of efforts to reorient health management, practices and investment in science, technology and innovation, even in services with consolidated policies. This is especially relevant in settings characterized by social, economic and demographic diversity permeated by technical, ethical and political specificities that promote the effectiveness of interventions³. In the present case, implementing innovative strategies to optimize the PHC apparatus in a capital city is even more challenging bearing in mind the central role PHC plays in coordinating care¹². Actions focused on this level of care therefore affect other levels, being capable of triggering processes and outcomes across the HCN.

The region in question is marked by problems inherent in major urban centers in Brazil, such as rapid growth, lack of planning, unemployment and deep social inequalities. Access to health services therefore continues to be a critical issue. The persistence of inequalities and other social problems has a significant impact on health-disease processes, especially coverage of the FHS¹⁷.

The project has made significant advances in this regard, especially considering the changes aimed at broadening access to PHC services. These advances were achieved by providing actions and services centered on the needs of the population⁴, including the adoption of innovative instruments such as the PHC service portfolio and Patient Notebook. It is worth mentioning that, despite the risks and obstacles encountered during the implementation of the actions, coverage of the FHS has increased significantly in the municipality. This increase in coverage warrants a mention because it was achieved despite the difficulties in the capital’s health districts, such as social structure and the prior existence of a disjointed care network based on traditional care models¹⁸.

However, it is important to bear in mind that increased coverage does not necessarily mean improved access to services. Coverage and access are different attributes that require specific assessments to take into account regional inequities, especially those involving vulnerability, and the inverse equity hypothesis¹⁹.

Advances were also made in the operation of SISREG, which was disjointed from PHC and limited to one regulation center. The proposal to decentralize appointment scheduling was accepted and the PHC doctors themselves now schedule appointments. Although there are problems that still need to be overcome in this regard and time series analyses needs to be conducted to obtain relevant data, this is a promising step forward because it addresses a major barrier to access to services in other levels of care. A study in Rio de Janeiro showed that the number of procedures, tests and scheduled appointments rose from 790,091 in 2011 to 1,469,771 in 2015 (an increase of 86%) as a result of the decentralization of appointment scheduling to family doctors²⁰. It is expected that similar results will be achieved in Campo Grande.

One of the problems encountered by the PHC teams is poor working conditions, more specifically physical infrastructure, care center environment and supply shortages. In this regard, actions are being developed to promote improvements in physical infrastructure and health team funding⁴. These actions seek to strengthen PHC as a health priority, investing in infrastructure and service organization²¹. It is known that the provision of adequate funding strengthens PHC, improves preventive service delivery to healthier populations and results in policies to promote primary care¹².

Training health professionals for PHC is a constant challenge in Brazil and was one of the priorities of the project. Focusing on family medicine and interprofessional residency programs, we concentrated our efforts on innovative teaching-learning processes guided by the needs of the local community. In this way, we strengthened the qualification of health workers and developed a professional training for PHC plan, thus supporting the recruitment of health professionals and helping to reduce staff turnover⁴.

In addition to improving the retention of health professionals, family and community training during residency and specialist training courses have a positive impact on a range of important health indicators. Studies showed that having adequately qualified staff reduced rates of hospitalization for ambulatory care sensitive conditions^5,10, enhanced care for patients with chronic conditions such as diabetes mellitus and hypertension⁵, improved maternal and infant health indicators¹¹, and resulted in stronger primary care orientation²⁰.

The project also develops actions to promote the integration of PHC and health surveillance to ensure that knowledge generation does not rely solely on epidemiological data from the health district, but also considers that these areas are living spaces permeated by a diverse range of social support settings and ways of life that reflect actions and reactions in the face of the health-disease process²¹. In this respect, the establishment of work processes centered on the specific health needs of the health district and willingness to engage with the community help improve resolvability and patient/worker satisfaction. These actions can facilitate outcomes that help services optimize performance against the attributes of primary care, with the ultimate aim of expanding access and improving the quality of care.

It is important to highlight that action planning was underpinned by the premises of institutional support. This device showed itself to be an important shared management strategy that drives improvements in health care and changes in work processes, bringing services, workers and managers closer together. This process is supported by ongoing critical analysis of care practices, aimed at producing local alternativas²² to tackle needs that require the reorientation of ways of providing health care.

This is particularly relevant considering the changing global burden of disease, deepening health inequities and insufficient past strategies²³. In this regard, throughout the project, we sought to create new services to respond to the differing sociodemographic, cultural, economic and epidemiological characteristics of local populations. We also considered elements that mobilize and modify the coordination of services (techniques and equipment) and the need to make improvements to the physical infrastructure and environment of care settings. Conceptually speaking, therefore, the actions implemented during the study period encompass product, process and organizational innovations³.

Thus, considering the actions implemented and results achieved during the study period, it is evident that INOVAAPS has cemented important advances with respect to the reorientation of the care model, training and retention of PHC professionals, coverage of the FHS, and HCN integration. Although it would be inappropriate to compare the different regions encompassed by laboratories for innovation due to the unique nature of each family health care setting, it is important to share experiences. In this respect, the actions presented here are aligned with the experiences of the Projeto Brasília Saudável (Healthy Brasília Project). With the aim of organizing the SUS for the full realization of health in the Federal District²⁴, this project has made significant progress in strengthening PHC.

Innovations in the field of PHC encompass various possibilities and there is still much to be done. However, we understand that innovative initiatives are movements that “come to be” and are not established “a priori”. This reflection is fitting bearing in mind that, despite the growth in biomedical breakthroughs in the prevention, treatment and diagnosis of diseases in recent years, there have been comparatively few innovations in our health systems to expand services and improve access to quality care in order to achieve more equitable health outcomes²³. On the other hand, nationally, it is important to consider that certain advances occur at a basic level, where PHC is permeated by a “...reality of poverty and dismantling of social policies, not just health [policies]...”¹⁷. This notion is important, because, undeniably, different political, organizational and social factors play a role, affecting to a greater or lesser extent the implementation and sustainability of the changes intended by policies²⁵.

It is vital to recognize this situation, especially in PHC, which is built on the premise of community alignment, which in turn is the foundation for quality health services, playing a critical role in achieving universal health coverage²³. Thus, in the face of the current socioeconomic situation, especially in developing countries like Brazil, the reorientation of PHC services for the implementation of innovations aligned with local realities is a differential factor for the reduction of disparities associated with socioeconomic deprivation¹².

During the project implementation process, relations of force inherent to initiatives that seek to reorient institutional practices were established. These relations are played out in fields of dispute, permeating the relational acts of the micropolitics of health care, power relations and intersubjective relations²⁵. They can thus act either as obstacles or to drive diverse ways of thinking and building innovation possibilities in the context of PHC and FHS, which is fulfilling its role of reducing inequalities in access to health services¹⁹ and consolidating itself as the best care model, with a capacity for innovation in management and communication technologies for health care⁴.

Thus, bearing in mind the path to be explored by the project over the coming years, by focusing on innovations in PHC, we are nested in a field of search for and discovery, experimentation and adoption of new knowledge, processes, products and forms of organization to offer something new to service users³. This is crucial in countries like Brazil, in which health systems have historically focused on episodic care for acute conditions and are poorly equipped to respond to the needs of the community throughout the life cycle²³.

Finally, it is important to highlight that this process took place during the COVID-19 pandemic, resulting in the need to make a number of adjustments to the planned actions and develop and implement a Covid-19 action plan in the municipality with the active participation of the teams involved in INOVAAPS.

Final considerations

The experience presented here is undergoing an ongoing construction and evaluation process, because we understand that the intentionality of innovation in the field of PHC should extend beyond the assumptions of normative and watertight planning. Thus, in view of the prior trajectories of the various actors involved, we believe that, in general terms, the findings presented here are promising and have the potential to trigger future outcomes that can open new fronts to strengthen PHC. In relation to the recommendations of Tasca et al.⁴, it can therefore be concluded that the actions implemented to date are focused on the consolidation and expansion of access to PHC, recruitment and training of adequately qualified professionals, adoption of resolutive technologies, regulatory improvement and strengthening the mediating role of PHC.

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Chief editors: Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva.

Publication Dates

• Publication in this collection
  30 June 2021
• Date of issue
  June 2021

History

• Received
  26 Oct 2020
• Accepted
  02 Feb 2021
• Published
  04 Feb 2021