The need to strengthen Primary Health Care in Brazil in the context of the COVID-19 pandemic

The emergence of severe acute respiratory coronavirus 2 (SARS-CoV-2) and its association with severe pneumonia and deaths has exposed gaps in the health systems of several countries worldwide. Although the necessary focus has been to care for hospitalized patients, the strengthening of Primary Health Care (PHC) actions is necessary. PHC is the gateway to the health system in several countries, including Brazil and it plays a role in preventing, protecting, promoting, and treating individuals and communities. Brazil, like other countries, has faced the SARS-CoV-2 pandemic. As Brazil has a universal and decentralized health system, in which PHC has been the model of health re-organizing the health system; here we reflected the importance of strengthening PHC in Brazil in the times of coronavirus disease 2019 pandemic.


Introduction
On February 26, 2020, 57 days after the Chinese government notified the World Health Organization (WHO) of an outbreak of pneumonia in Wuhan, capital of Hubei, 1 the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed by the first time in Brazilian territory and, since then, the virus that causes coronavirus 2019 (COVID-19) has been spreading throughout the country. 2 Until April 15, 2020, when we wrote this paper, there are already 28,320 confirmed cases (an increase of 3,058 in 24 hours) and 1,736 deaths (an increase of 204 deaths in 24 hours). 2 Here we reflected the importance of strengthening PHC in Brazil in the times of coronavirus disease 2019 pandemic.

Unified Health System and the response to the COVID-19 pandemic
In Brazil, the Unified Health System (SUS), established in the 1980s for universal and whole care, has the fundamental mission of guaranteeing care for more than 210 million Brazilians and thousands of foreigners residing or passing through the country. 3 In face of COVID-19, SUS assumes a fundamental role in the containment of the disease in Brazil, using a wide network of hospitals, laboratories, research centers, health units, blood bank and blood products, private network linked to institutions support, and public universities.
Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.
To prevent or at least delay the collapse of the health system -already observed in other countries -a set of measures were adopted by the Brazilian government. Brazil hired more than 200 beds of intensive care units (ICU) and more than 5,800 doctors for the Mais Médicos (More Doctors) Program in Brazil", especially to work in large urban centers where high population density is observed. The government granted US$ 2 billion for private plans to invest in infrastructure, acquisition, and distribution of 10 million rapid tests for SARS-CoV-2 infection in the states and municipalities. Additionally, US$ 200 million were destinated for the acquisition of respirators, US$ 10 million for scientific studies and transferred US$ 0.9 billion from the Insurance for Traffic Accidents fund to SUS (4). Despite such measures, the health system has failed to guarantee comprehensive assistance to citizens and the risk of collapse has become increasingly evident and predictable.

Primary Health Care and COVID-19 pandemic
With all the concern focused on the hospital network, one component of the system has been overlooked: Primary Health Care (PHC). In the plan to combat COVID-19 epidemic in Brazil, there is no explicit and/or clearly mention of investment and/or strengthening of this component of the health system. 4 We advocate that failing to appreciate the importance of PHC in this pandemic moment can be a mistake in favor of the rapid collapse of the health system in the face of the increase in cases of COVID-19 in the country.
In recent years, this is the component of SUS that has been weakened the most 5  There are reasons to believe that enhancing PHC in this pandemic moment can be a potent alternative. The Family Health Strategy (ESF), initially created as the Family Health Program (PSF) in the early 1990s, has been the main instrument for reorienting Brazilian healthcare practice and consolidating PHC in Brazil. 6 In 1998, Brazil had 2,054 family health teams; in 2017, there were already 41,619, covering 70% of the Brazilian population (about 143 million people). 7 The Mais Médicos (More Doctors) Program was responsible for an accelerated growth in family health coverage between 2014 and 2017, whose coverage went from 66.9% to 70.0%. The PHC workforce involved more than 36,000 health posts, 63,000 doctors, 70,000 nurses, 263,000 community health workers and 26,000 oral health teams. 8 With a resolution rate of around 85% of the population's basic health needs, PHC was responsible, between the years 2001 and 2016, for reducing 45% of hospitalizations for conditions sensitive to this level of care (76% in hospitalizations for asthma, 66.5% in hospitalizations for gastroenteritis and 57.3% of hospitalizations for cardio and cerebrovascular diseases, for example). 7 In municipalities with Mais Médicos (More Doctors) program, the reduction in these admissions was 4% greater than in those without the program. 9 Immunization is also an essential attribute of PHC. The increase in vaccination coverage results in a reduction in hospitalization due to preventable diseases, such as whooping cough, diphtheria, H. inf luenzae and measles. Currently, there are more than 36,000 vaccine rooms and 45 types of immunological, including vaccines, serum and immunoglobulins. 10 SUS is responsible for 95% of vaccine doses applied in the country. 10 Because of the pandemic, Brazil decided to anticipate, in one month, the beginning of vaccination against Influenza, a seasonal respiratory disease that increases the number of hospitalizations, which may represent an additional burden on the health system. The campaign aims to immunize at least 90% of the target population, made up of 67.6 million individuals.
Established in 2011 by the Brazilian Ministry of Health, the Telehealth program (Programa Telessaúde, in Portuguese) has been an additional tool used by health References professionals and managers to combat COVID-19. By means of bidirectional telecommunication instruments, health professionals and managers can send their doubts about clinical management, preventive actions or even issues related to the work process; and a qualified professional sends the requesting professional information based on the current scientific evidence. 11 This has allowed to qualify the care provided in the PHC and to reduce unnecessary referrals of users to more specialized levels.
A strong primary care may reduce unnecessary admissions, relieving the hospital system and expanding the availability of beds for patients with COVID-19 and can save financial resources for the health system itself and guarantee its sustainability. 12 Between 2010 and 2016, more than 23,000 hospitalizations for conditions sensitive to primary care were avoided, generating savings of US$ 6.1 million to public coffers in Brazil. 8

Conclusion
The important role that PHC has in facing the COVID-19 pandemic is notorious. Governments should spare no effort to strengthen this component of the system, at risk of worsening the health crisis, rapid collapse of the health system and an increase in the number of deaths from both COVID-19 13 and other conditions sensitive to changes in PHC, including diarrheal disease, respiratory and cardiovascular diseases. Thus, PHC represents a strategic resource in the limited arsenal of tools available to combat COVID-19.