Primary Care and Care Continuity in the Context of a Health Crisis: Lessons Learned from the Brazilian Reality

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It is distinguished from other care levels by its essential attributes: longitudinality, first-contact care, comprehensiveness, and care coordination across the network. PHCs played a crucial role during the COVID-19 pandemic, and providing continuous care while coordinating testing and contact tracing was challenging. It is necessary to adapt its operations to ensure care. This study explores the influence of essential PHC attributes and local organizational strategies on care continuity during the pandemic. Methods : A quantitative cross-sectional study was conducted with health managers from municipalities in the state of São Paulo in a sample stratified by population size. The survey was applied in 259 municipalities, and the weighted analysis considered 553 municipalities. We evaluated indicators related to care continuity in PHC, convergence with essential PHC attributes, local strategies such as telecare, and the adaptation of PHC units (UBSs) to an exclusive COVID-19 PHC service. Statistical analyses included Pearson’s correlation and multiple linear regression. Results: Care continuity in PHC was significantly associated with convergence of essential PHC attributes (r=0.453, p=0.000), PHC coverage, investment in telecare, and the transformation of UBS to care exclusively for COVID-19 patients. The regression model revealed that these variables significantly influenced care maintenance during the pandemic, and convergence of essential PHC attributes was the most relevant factor. Conclusion : Convergence in the essential attributes of comprehensive PHC was crucial for care continuity during the pandemic. Owing to the essential attributes of comprehensive PHC, continued strengthening of PHC is necessary to ensure the resilience of health systems, and we recommend future studies on the implementation of the essential attributes of comprehensive PHC. Primary health care Health systems Health services Healthcare models Comprehensive health care Continuity of patient care Brazil COVID-19 Background Primary health care (PHC) has played a fundamental role in improving global health and well-being for over 40 years, resulting in a significant decline in maternal, neonatal, and child mortality and deaths from diseases such as HIV/AIDS, malaria, tuberculosis, and vaccine-preventable diseases [ 1 , 2 ]. The main distinctions between PHC and other care levels are the fundamental attributes guiding care: longitudinality, first-contact care, comprehensiveness, and care coordination in the network [ 3 ]. The organization of these attributes may vary under different health systems. However, PHC attributes tend to be strengthened with proximity to the territory, community care initiatives, and investment in professionals trained to work with family and community medicine [ 3 , 4 ]. Thus, we would have comprehensive primary health care available to users with these strengthened PHC attributes. Comprehensive primary health care (PHC) is even more important when its effectiveness in low- and middle-income countries is considered. Robust evidence indicates that implementing a comprehensive PHC approach in these countries ensures equitable access to care and protection against financial hardship [ 5 , 6 ]. Thus, PHC is widely recognized as essential for achieving universal health coverage and reducing health inequalities [ 7 ]. Research has highlighted the importance of PHC during the COVID-19 pandemic [ 8 , 9 ], which can be understood as a recent example of a severe health crisis on a global scale. During the crisis, PHC served as the first point of contact for individuals and communities and displayed the ability to adapt quickly during the pandemic [ 10 – 12 ]. In many places, PHC is responsible for coordinating testing, contact tracing, and monitoring patients in home isolation, which significantly affects the spread of the virus [ 13 ]. PHCs’ ability to integrate preventive and curative care, offering a comprehensive care continuum, is crucial for preventing the collapse of health systems and ensuring that vulnerable populations continue to receive the care they need [ 14 ]. However, during the health crisis caused by the COVID-19 pandemic, concerns have been raised about care continuity [ 8 , 15 ], especially for the population with chronic noncommunicable diseases and other conditions usually treated in PHC [ 10 ], such as immunization and maternal and child care. Several responses were identified for care continuity in PHC. Some of the principal adaptations already mapped that reorganized care were telemedicine and telephone or video call appointments, virtual monitoring of patients, and reallocating the flow to specific units designated for COVID-19 cases [ 10 , 12 , 16 – 18 ]. However, we observe persistent gaps in the understanding of the role of previous structuring of PHC’s essential attributes (comprehensive PHC) in the responses implemented during the COVID-19 pandemic, especially regarding the associations between PHC attributes before the pandemic and dedicated care continuity responses. The Brazilian Unified Health System (SUS) is an interesting case for investigating this possible association. The SUS has continental proportions and aims to provide comprehensive healthcare to all citizens at the individual, family, and collective levels in PHC and specialized care. The SUS is under tripartite management, involving the federal, state, and municipal spheres that work together to finance and formulate health policies [ 19 ]. The municipalities (the spheres with the least state capacity [ 20 ] and the greatest territorial capillarity) are responsible for most of the provided services [ 21 ], especially PHC. Given the large number of municipalities, 5,570 in total [ 22 ], we observe significant internal heterogeneity in Brazilian PHC regarding the implementation of comprehensive PHC attributes. The state of São Paulo is among the most populous in the country within the Brazilian system. It harbors 645 municipalities of different population sizes and varying levels of access to the specialized care network. It was one of the primary COVID-19 epicenters. São Paulo’s PHC has different configurations regarding the care model adopted and has developed heterogeneous care guidelines for the pandemic [ 14 , 23 ]. In conjunction with these aspects, the state of São Paulo can be taken as an interesting excerpt to constitute an analyser of the institutional care culture in Brazilian PHC, as it encompasses services in their most varied ways of implementing attributes. This study explores the influence of essential PHC attributes and local strategies for organizing actions on municipalities' performance in preserving care continuity during the COVID-19 pandemic. Methods Study design and participants This is a quantitative cross-sectional study with municipal health managers due to their role in decision-making on guidelines for organizing care within PHC. The study population consisted of a probabilistic sample of municipalities in the state of São Paulo stratified by population size to allow the analysis of characteristics in different settings. Thus, the sample was drawn from three strata: (i) municipalities with 50,000 inhabitants or more (n=139); (ii) municipalities with between 10,000 and 50,000 inhabitants (n=239); and (iii) municipalities with up to 10,000 inhabitants (n=267). Stratum (i) municipalities with 50,000 inhabitants or more were surveyed in a census fashion for 139 municipalities, of which 132 participated in the study. For strata (ii) and (iii), the samples were defined using the presence of traditional PHC and ESF teams as criteria, totaling, in stratum (ii), a sample of 60 municipalities and, in (iii), a sample of 60 municipalities. In stratum (ii), 66 of the 60 planned participants and 55 of the 60 sampled participants were interviewed in stratum (iii). The three strata together generated a sample of 259 municipalities, of which 253 agreed to respond to the survey. Thus, sample losses corresponded to six municipalities and occurred due to refusal or inability to participate due to recent changes in management positions. The sample weights were calculated, and a weighted sample of 553 municipalities was obtained. In Brazil, the family health strategy (ESF) model is similar to that of comprehensive PHC. Thus, in this article, we refer to ESF teams as comprehensive PHCs and traditional PHC teams as representatives of services with little investment in essential PHC attributes. Data collection Data were collected from February to June 2022 through telephone or video call surveys. The form was structured on the RedCap platform and organized into seven blocks: (i) PHC model; (ii) general characteristics of PHC management in the municipality; (iii) initial adaptation to the pandemic context; (iv) COVID-19 health actions (2020 and 2021); (v) continuity of PHC activities (2020 and 2021); (vi) general impressions; and (vii) successful experiences during the pandemic. The characterization of the previous PHC structure on the basis of essential attributes was concentrated in blocks (i) and (ii); the organization of services in a health crisis was represented on the basis of the response to COVID-19, blocks (iii) and (iv); and care continuity, blocks (v), (vi) and (vii). During the questionnaire application, responses could be provided by municipal health secretaries, the PHC coordinator, the health director, or a similar position. Variables On the basis of the questions in the questionnaire and the literature, we selected indicators that characterized the PHC’s level of convergence with the essential attributes (longitudinality, first contact, comprehensiveness, and care coordination) in the municipality and performance in preserving care continuity during the pandemic. In this study, we selected distinctive PHC aspects regarding the essential attributes described for this care level, which resonate with the guidelines for organizing Brazilian PHC services, considering the model [3,23,24] of ESF teams (Box 1). Box 1 Work process changes to adapt to the current health crisis (COVID-19) were captured through questions related to technological improvements aimed at conducting telehealth appointments [10,11] and telecare and questions related to establishing the referral flow for patients with suspected or diagnosed COVID-19 within the PHC by establishing an exclusive COVID-19 PHC service or separating PHC units exclusively for COVID-19 care. Care continuity during the pandemic was assessed through nine dimensions (Box 2). Box 2 In addition to the variables in the questionnaire, the potential population coverage of the existing PHC teams in the municipality and the municipality’s population were added to the analysis. The potential coverage of PHC teams was retrieved from the Ministry of Health’s PHC website [25], which has information on the number of funded Family Health and PHC teams, considering the potential population served by the team (data referring to the registration status in August 2021). The population of the municipality was obtained from the State Health Secretariat’s website [26], considering the population estimate for 2021, calculated by the SEADE Foundation, on the basis of a reprojection based on the 2022 Census. Thus, the variables included in the study were named as follows: Comprehensive PHC: Score of the convergence score with comprehensive PHC; Investment in telecare: Investment in telecare score in PHC; PHC with flow for RS: Separate care flows for patients with respiratory symptoms (RS) within the PHC unit; Establishing an exclusive COVID-19 PHC service: Creating a new service to provide COVID-19 care; Exclusive PHC COVID-19 services: Transforming a PHC service to operate as a dedicated COVID-19 care center; Care continuity in PHC: PHC care continuity score; PHC coverage: Population coverage by PHC health teams; Population: Number of inhabitants in the municipality. Data analysis All the analyses were weighted on the basis of the sampling weights defined in the sampling process. The data analysis model considered care continuity in PHC as the dependent variable. Pearson’s correlation coefficient, which is based on a correlation matrix, initially measures the dependence between variables. Multiple linear regression analysis (stepwise method) was subsequently performed with all the variables of interest. A logarithmic transformation was performed to achieve a normal distribution of the population variables. The data were analysed via the SPSS TM statistical package version 20, assuming a statistical significance level of 5%. Results Table 1 shows a summary description of the variables included in this study per care continuity in PHC. In this table, we can observe a consistent association between care continuity in PHC and the variables of PHC convergence, PHC coverage, the transformation of UBS for exclusive COVID-19 care, and telecare initiatives. These variables had p<0.05 according to the chi-square test. The municipal population was not significantly associated with care continuity in PHC, where 40.2% of the municipalities had a population of up to 10,000, and 23.0% had a population above 50,000. Table 1. Description of the variables included in the study by score of care continuity in PHC. São Paulo State, 2022 Variable Value Care continuity in PHC P-value * 00-28 29-39 40-51 50+ Total Comprehensive PHC 00-06 42.9% 32.4% 18.2% 14.8% 28.0% .000 07-09 32.5% 35.0% 37.9% 11.9% 29.3% 10-12.5 18.3% 18.5% 21.6% 22.4% 20.1% 12.6-and above 6.2% 14.1% 22.3% 50.9% 22.5% Total 100.0% 100.0% 100.0% 100.0% 100.0% PHC coverage 00-42 25.9% 15.1% 13.5% 7.5% 16.1% .000 42.1-66 14.7% 14.2% 23.8% 15.8% 16.9% 66.1-and above 59.4% 70.7% 62.7% 76.8% 66.9% Total 100.0% 100.0% 100.0% 100.0% 100.0% Creating a COVID-19 care center No 29.0% 26.7% 23.9% 32.3% 28.1% .476 Yes 71.0% 73.3% 76.1% 67.7% 71.9% Total 100.0% 100.0% 100.0% 100.0% 100.0% Population Up to 10,000 h 40.5% 36.5% 33.4% 49.8% 40.2% .123 10,001 to 50,000 h 38.9% 40.7% 39.1% 28.5% 36.8% More than 50,000 h 20.6% 22.8% 27.6% 21.6% 23.0% Total 100.0% 100.0% 100.0% 100.0% 100.0% Exclusive COVID-19 PHC service No 52.4% 57.3% 69.6% 66.7% 61.0% .009 Yes 47.6% 42.7% 30.4% 33.3% 39.0% Total 100.0% 100.0% 100.0% 100.0% 100.0% PHC with care flow for RS No 28.7% 23.2% 21.8% 21.2% 24.0% .403 Yes 71.3% 76.8% 78.2% 78.8% 76.0% Total 100.0% 100.0% 100.0% 100.0% 100.0% Investment in virtual care Low 67.4% 68.1% 52.2% 30.8% 55.2% .000 Medium 21.5% 18.5% 26.3% 33.4% 24.8% High 11.1% 13.4% 21.5% 35.9% 20.0% Total 100.0% 100.0% 100.0% 100.0% 100.0% Table 1 A Pearson correlation matrix is shown in Table 2, including all the variables selected for the study. Initially, we underscore the correlation between care continuity in PHC and PHC convergence in comprehensive PHC (r=0.453, p=0.000). Other variables were also significantly correlated but with less intensity: UBS transformation (r= -0.109, p=0.011), investment in telecare (r= 0.295, p=0.000), separate care flow in UBS for patients with respiratory symptoms (r= 0.110, p= 0.009), and PHC coverage (r= 0.111, p= 0.009). PHC coverage was also strongly correlated with population size (r= -0.662, p= 0.000). Table 3 shows the results of the multiple linear regression analysis, where care continuity in PHC was considered the dependent variable. Convergence on the attributes of comprehensive PHC, investment in telecare, transforming the UBS into an exclusive COVID-19 PHC service, and PHC coverage were included in this model, with significant ß values of 0.384, 0.220, -0.136, and 0.106, respectively. Table 2. Correlation between care continuity and variables of interest. State of São Paulo, 2022. Variable Care continuity Comprehensive PHC attributes Population of the municipality Implementation of a new COVID-19 Care Center Transformation of UBS into COVID-19 Care Center Investment in virtual care in PHC Separation of care flows for patients with respiratory symptoms in the UBS Comprehensive PHC attributes Pearson’s Correlation 0.453 * P-value 0.000 Population Pearson’s Correlation 0.046 0.114 * P-value 0.284 0.007 Implementation of a new COVID-19 Care Center Pearson’s Correlation -0.010 0.071 0.221 * P-value 0.807 0.095 0.000 Transformation of UBS into COVID-19 Care Center Pearson’s Correlation -0.109 * 0.018 -0.066 0.067 P-value 0.011 0.679 0.120 0.118 Investment in virtual care Pearson’s Correlation 0.295 ** 0.268 * 0.208 * 0.166 * 0.082 P-value 0.000 0.000 0.000 0.000 0.055 Separation of care flows for patients with respiratory symptoms in the UBS Pearson’s Correlation 0.110 * 0.108 * -0.004 -0.105 * -0.025 0.086 * P-value 0.009 0.011 0.919 0.014 0.555 0.044 PHC Coverage Pearson’s Correlation 0.111 * 0.113 * -0.662 * -0.151 * 0.023 -0.161 * 0.084 * P-value 0.009 0.008 0.000 0.000 0.597 0.000 0.048 * Statistically significant. Table 3. Multiple linear regression between care continuity and associated variables. State of São Paulo, 2022. Variables Coefficients ß (Non-Standardized) ß (Standardized) Sig. Constant 16.964 0.000 Comprehensive PHC attributes 1.612 0.384 0.000 Investment in virtual care in PHC 1.617 0.220 0.000 Transformation of UBS into COVID-19 Care Center -4.591 -0.136 0.000 PHC Coverage 0.064 0.106 0.005 Note: R 2 = 0.265 Table 2 Table 3 Discussion This study analysed PHC’s capacity to maintain routine health actions during a health crisis, such as the COVID-19 pandemic. We should discuss PHC organization in this context of crisis because system overload at all care levels has challenged the reorganization of routine appointments and preservation of care for other health problems during the pandemic [ 10 , 12 , 16 ]. We analysed attributes in the organization of actions in PHC to assess its potential as a comprehensive PHC. We also verified the scope of PHC prepandemic coverage in each municipality and considered strategies adopted by the municipality to address COVID-19. The results showed that PHC’s ability to maintain care continuity depended on an organizational model prioritizing comprehensive care, extended PHC population coverage, and municipal strategies for investing in PHC telecare. The municipal strategy of transforming one or more PHC services into an exclusive COVID-19 care service negatively impacted care continuity in PHC. Care continuity was already a concern for PHC even before the COVID-19 pandemic [ 27 , 28 ]. However, in the context of the pandemic, services had to be reorganized to include the new demands arising from the pandemic. The analysis of convergence on the comprehensive PHC revealed that the participation of the essential PHC attributes (longitudinality, comprehensiveness, linkage, first access, and care coordination) is structuring the organization of services, albeit with different convergence levels. Therefore, the case of São Paulo illustrates the possibility of taking the previous structure and organizational aspects of the work of PHC teams as prepandemic variables to identify the influence of comprehensive PHC on the system's response at this care level during the health crisis. In addition to this comprehensive PHC perspective, the population coverage of PHC teams enhances an adequate response to the pandemic situation [ 24 ]. Establishing bonds of trust that encourage the use of PHC as the first access and working conditions aligned with the attributes of longitudinality, comprehensiveness, and coordination of PHC are crucial points to promote continued care even during health crises [ 24 ]. On the other hand, the association between care continuity and establishing exclusive COVID-19 PHC services was negative. Although separating the public served between services could seemingly produce a relieving effect so that other PHC services can dedicate themselves to other demands and problems, this hypothesis was not proven true. Separating the target audience brought a rupture of the first access and comprehensiveness attributes, thus compromising longitudinality and, by extension, care continuity. In this sense, the simultaneous functioning of the attributes of comprehensive PHC is vital to preserving the care continuity effect [ 12 ]. Furthermore, separate flows can lead to the reallocation of flows and people, affecting interprofessionality and teamwork, which also tend to harm care continuity [ 29 ], whether within or outside the context of a health crisis. São Paulo’s data align with results from the rest of Brazil [ 18 , 24 , 30 ] and show the relevance of promoting comprehensive PHC and converging on this type of care organization to advance care longitudinality and territorialization, highlighted during the pandemic. The results also reinforce the idea that it is crucial to reverse the scenario of changes promoted in health systems and PHC [ 31 – 35 ] to have health systems prepared for care continuity even during health crises, which tend to reduce financing and the scope of care and can restrictively affect the scope of care offerings and threaten the consolidation of PHC’s essential attributes. Converging to comprehensive PHC was more strongly associated with care continuity than were the other variables analysed. Thus, it should gain prominence in discussions on strengthening health systems. The PHC coverage estimated in this study was based on the number of existing health teams, revealing its importance regarding the results of PHC actions, as it was significantly associated with care continuity during the pandemic period. In the national setting, the associations between a well-established PHC system with good population coverage and health outcomes for these populations are already known [ 36 – 38 ]. However, the state of São Paulo has shown low PHC coverage indicators over the last few decades compared with other federated units [ 23 , 39 ], with significant regional differences and a tendency towards better coverage in municipalities with smaller populations. [ 40 ] Following the example of PHC experiences in other countries, technological investments have also been made in several municipalities in Brazil to implement telecare [ 10 ] within PHC, meeting the requirements of minimizing social contact during the pandemic period. Telecare was positively associated with care continuity in PHC. However, advances in telecare must be designed to converge on PHC’s essential attributes. The Brazilian case study, with its internal diversity, shows that it is necessary to invest in expanding and consolidating the attributes of comprehensive PHC, which promotes more comprehensive and integrated care [ 6 , 30 ], to strengthen PHC so that it can provide adequate responses in health crises such as the COVID-19 pandemic. There is an urgent need to implement robust policies that support the expansion of PHC in terms of its essential attributes and that encourage adaptation and healthcare continuity at all care levels to ensure the efficiency and resilience of health systems. Study limitations The study’s limitation was its geographic scope, which adopted only one Brazilian state. However, internal diversity minimizes this aspect, which affects municipalities of different population sizes and with different health service structures. It also limited the care continuity analysis to actions related to children and pregnant women of users with NCDs, as they represent priority groups in PHC. Conclusion The findings presented here align with efforts already established globally to “reference” lessons learned during the COVID-19 pandemic and show the relevance of resuming discussions on the guidelines that should guide comprehensive PHC and its role in public health policies applicable to all health systems. This study reaffirms the relevance of comprehensive PHC, highlighting that its guidelines have been vital for territorialization, continuous access, and comprehensive care despite its variations. Furthermore, converging on the essential attributes of comprehensive PHC was especially crucial for care continuity. During the COVID-19 pandemic, the recovery of priority activities in PHC has shown that it is possible to maintain longitudinal actions such as prenatal care, childcare, home visits, and care for users with NCDs, even in municipalities with a smaller structure but with aspects linked to the essential attributes of comprehensive PHC. Therefore, continued and robust investments in comprehensive PHC are needed to prepare the system, ensuring that health professionals deeply understand the living conditions of communities and develop a diverse range of skills and abilities. This strengthening is essential for ensuring the resilience and effectiveness of health systems in different contexts and structures. We recommend further studies detailing the implementation of PHC’s essential attributes to guide health systems in implementing comprehensive PHC. Abbreviations PHC: Primary Health Care UBS: Primary health care units SUS: Brazilian Unified Health System ESF: Family Health Strategy RS: Respiratory Symptoms Declarations Availability of data and materials The data described in this article can be freely and openly accessed at Harvard Dataverse: https://doi.org/10.7910/DVN/KP7Y5A Authorship Declaration Ethics Approval and Consent to Participate This study was conducted in compliance with current ethical standards and with the approval of the Ethics Committee of the Health Institute. All participants provided informed consent prior to their involvement in the study. Consent for Publication All authors confirm their awareness of and agreement with the submission and potential publication of this manuscript in BMC Primary Care. The parties involved, including collaborating and funding institutions, have approved the dissemination of results. Availability of Data and Materials The data described in this article can be freely and openly accessed at Harvard Dataverse:https://doi.org/10.7910/DVN/KP7Y5A Competing Interests The authors declare that there are no relevant competing interests in this study. Funding This work was funded by FESIMA - Health Secretariat - Government of the State of São Paulo (Brazil). The funding agency had no role in the conception, data collection, analysis, decision to publish, or manuscript preparation. Authors' Contributions All authors made significant contributions to the development of this study. Mônica Martins de Oliveira Viana coordinated the research and manuscript preparation. Mônica Martins de Oliveira Viana, Mariana Tarricone Garcia, Lígia Schiavon Duarte, Arnaldo Sala, Maria Izabel Sanches Costa, and Michelle Fernandez contributed to data collection, analysis, and article writing. Barbara Martins Pontes managed the data repository. 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Castanheira ERL, et al. Organização da atenção primária à saúde de municípios de São Paulo, Brasil: modelo de atenção e coerência com as diretrizes do Sistema Único de Saúde. Cadernos Saude Publica. 2024;40(2):PT099723. doi:10.1590/0102-311XPT099723. Schenkman S, et al. Padrões de desempenho da atenção primária à saúde diante da COVID-19 no Brasil: características e contrastes. Cadernos Saude Publica. 2024;39(8):e00009123. doi:10.1590/0102-311XPT009123. Ministério da Saúde. E-gestor Atenção Básica: financiamento da APS. Available from: https://egestorab.saude.gov.br/gestaoaps/relFinanciamento.xhtml. Secretaria de Estado da Saúde (SP). Informações de saúde: indicadores de saúde. Available from: https://www.saude.sp.gov.br/ses/perfil/profissional-da-saude/informacoes-de-saude-/tabnet-ses-indicadores-de-saude. Soares DA, Kochergin CN, Mistro S, Macedo JCL, Carvalho VCH dos S de, Oliveira MG. Atenção Primária à Saúde abrangente: análise a partir do trabalho das equipes de Saúde da Família frente às doenças crônicas. Physis [Internet]. 2024;34:e34015. Available from: https://doi.org/10.1590/S0103-7331202434015pt Viacava F, et al. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cienc Saude Colet. 2018;23(6):1751-62. doi:10.1590/1413-81232018236.06022018. Mayo AT. Teamwork in a pandemic: insights from management research BMJ Leader 2020;4:53-56. doi:10.1136/LEADER-2020-000246. Engstrom E, Teixeira MB, Oliveira R, Vianna SM, Gonçalves AS. Recomendações para a organização da atenção primária à saúde no SUS no enfrentamento da Covid-19. Observatório Covid-19: Série Linda de cuidado Covid-19 na Rede de Atenção à Saúde. Rio de Janeiro: Fiocruz; 2020. Cordilha, A. C., & Lavinas, L.. (2018). Transformações dos sistemas de saúde na era da financeirização. Lições da França e do Brasil. Ciência & Saúde Coletiva, 23(7), 2147–2158. https://doi.org/10.1590/1413-81232018237.11422018 Mathews M, Hedden L, Lukewich J, Hayes-McNeill T, Dorgan M. Adapting care provision in family practice during the COVID-19 pandemic: a qualitative study exploring the impact of primary care reforms in four Canadian regions. BMC Prim Care. 2024;25(1): 52. doi:10.1186/s12875-024-02024-8. PMCID: PMC8923183. Filippon, J., Giovanella, L., Konder, M., & Pollock, A. M.. (2016). A "liberalização" do Serviço Nacional de Saúde da Inglaterra: trajetória e riscos para o direito à saúde. Cadernos De Saúde Pública, 32(8), e00034716. https://doi.org/10.1590/0102-311X00034716 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Ciênc saúde coletiva [Internet]. 2018Jun;23(6):1723–8. Available from: https://doi.org/10.1590/1413-81232018236.09172018 Brandão JR de M. A atenção primária à saúde no Canadá: realidade e desafios atuais. Cad Saúde Pública [Internet]. 2019;35(1):e00178217. Available from: https://doi.org/10.1590/0102-311X00178217 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Ciênc Saúde Coleta [Internet]. 2020;25(4):1475-82. doi: 10.1590/1413-81232020254.01842020. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde Debate . 2018;42(Spec 1):18-37. doi: 10.1590/0103-11042018S102. Daumas RP, Silva GA e, Tasca R, Leite I da C, Brasil P, Greco DB, et al.. O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da COVID-19. Cad Saúde Pública [Internet]. 2020;36(6):e00104120. Available from: https://doi.org/10.1590/0102-311X00104120 Giovanella L, Bousquat A, Schenkman S, Almeida PF, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Ciênc Saúde Colet . 2021;26(Suppl 1):2543-56. doi: 10.1590/1413-81232021266.1.43952020. Brasil. Ministério da Saúde. e-Gestor Atenção Primária à Saúde - Relatórios APS - Cobertura Potencial da APS (2021 - atual). Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml Box Box 1. Aspects considered for scoring the convergence score with the comprehensive PHC. Aspects Score variation Territorialization process 1 to 3 Guidance on access to PHC offered to users 2 to 3 Continuity of care by the same team 0 to 3 Medical care provided by a family doctor or general practitioner 0 to 3 Activities performed by community health workers 0 to 3 Available counter-referral flow between health services 1 to 3 Box 2. Aspects considered for scoring care continuity during the COVID-19 pandemic. Aspects Score variation Home visits -1 to 3 Activities performed by PHC during home visits 0 to 3 Prenatal care appointments -1 to 3 Activities performed by PHC during prenatal care appointments 1 to 3 Childcare -1 to 3 Activities performed by PHC during childcare 1 to 3 Appointments for chronic diseases -1 to 3 Activities performed by PHC during appointments for chronic diseases 1 to 3 Participants' self-assessment of their performance in providing care continuity for priority groups (pregnant women, children aged 0-2 years, and people with chronic diseases) 0 to 3 Additional Declarations No competing interests reported. Supplementary Files DataBaseCOVIDAPS.xlsx Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2026 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 06 Nov, 2024 Editor assigned by journal 04 Nov, 2024 Submission checks completed at journal 04 Nov, 2024 First submitted to journal 31 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5369192","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374646206,"identity":"2ba4ba46-6e3b-46a2-8511-8bd4e027aadf","order_by":0,"name":"Mônica Martins Oliveira Viana","email":"","orcid":"","institution":"Instituto de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Mônica","middleName":"Martins Oliveira","lastName":"Viana","suffix":""},{"id":374646207,"identity":"1f1dc5b0-2508-48cd-a048-6d234a5d8d46","order_by":1,"name":"Mariana Tarricone Garcia","email":"","orcid":"","institution":"Instituto de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Mariana","middleName":"Tarricone","lastName":"Garcia","suffix":""},{"id":374646208,"identity":"c7a8fe21-7b70-4410-8f36-1bf03695e78e","order_by":2,"name":"Maria Izabel Sanches Costa","email":"","orcid":"","institution":"Instituto de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Izabel Sanches","lastName":"Costa","suffix":""},{"id":374646209,"identity":"a949945c-358d-4045-a75e-3e406c91659a","order_by":3,"name":"Lígia Schiavon Duarte","email":"","orcid":"","institution":"Instituto de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Lígia","middleName":"Schiavon","lastName":"Duarte","suffix":""},{"id":374646210,"identity":"10d7d253-f769-4081-aadf-b29f597cfbc3","order_by":4,"name":"Arnaldo Sala","email":"","orcid":"","institution":"Secretaria do Estado da Saúde de São 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Viana","email":"data:image/png;base64,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","orcid":"","institution":"Instituto de Saúde","correspondingAuthor":true,"prefix":"","firstName":"Mônica","middleName":"Martins Oliveira","lastName":"Viana","suffix":""}],"badges":[],"createdAt":"2024-10-31 21:08:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5369192/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5369192/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-026-03296-4","type":"published","date":"2026-04-09T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":106808818,"identity":"3d53587b-fc72-4c23-b755-4e4a71e5b8e3","added_by":"auto","created_at":"2026-04-13 16:02:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327322,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5369192/v1/be19c0a2-3e32-4ac4-bded-d59eb2c5f8fd.pdf"},{"id":69055464,"identity":"25a90785-de9a-4cbe-8c25-3dcb21701deb","added_by":"auto","created_at":"2024-11-15 06:20:43","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":56934,"visible":true,"origin":"","legend":"","description":"","filename":"DataBaseCOVIDAPS.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5369192/v1/e05af56db2d544dc02973913.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePrimary Care and Care Continuity in the Context of a Health Crisis: Lessons Learned from the Brazilian Reality\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary health care (PHC) has played a fundamental role in improving global health and well-being for over 40 years, resulting in a significant decline in maternal, neonatal, and child mortality and deaths from diseases such as HIV/AIDS, malaria, tuberculosis, and vaccine-preventable diseases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The main distinctions between PHC and other care levels are the fundamental attributes guiding care: longitudinality, first-contact care, comprehensiveness, and care coordination in the network [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The organization of these attributes may vary under different health systems. However, PHC attributes tend to be strengthened with proximity to the territory, community care initiatives, and investment in professionals trained to work with family and community medicine [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thus, we would have comprehensive primary health care available to users with these strengthened PHC attributes.\u003c/p\u003e \u003cp\u003eComprehensive primary health care (PHC) is even more important when its effectiveness in low- and middle-income countries is considered. Robust evidence indicates that implementing a comprehensive PHC approach in these countries ensures equitable access to care and protection against financial hardship [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, PHC is widely recognized as essential for achieving universal health coverage and reducing health inequalities [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch has highlighted the importance of PHC during the COVID-19 pandemic [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which can be understood as a recent example of a severe health crisis on a global scale. During the crisis, PHC served as the first point of contact for individuals and communities and displayed the ability to adapt quickly during the pandemic [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In many places, PHC is responsible for coordinating testing, contact tracing, and monitoring patients in home isolation, which significantly affects the spread of the virus [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. PHCs\u0026rsquo; ability to integrate preventive and curative care, offering a comprehensive care continuum, is crucial for preventing the collapse of health systems and ensuring that vulnerable populations continue to receive the care they need [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, during the health crisis caused by the COVID-19 pandemic, concerns have been raised about care continuity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], especially for the population with chronic noncommunicable diseases and other conditions usually treated in PHC [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], such as immunization and maternal and child care.\u003c/p\u003e \u003cp\u003eSeveral responses were identified for care continuity in PHC. Some of the principal adaptations already mapped that reorganized care were telemedicine and telephone or video call appointments, virtual monitoring of patients, and reallocating the flow to specific units designated for COVID-19 cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, we observe persistent gaps in the understanding of the role of previous structuring of PHC\u0026rsquo;s essential attributes (comprehensive PHC) in the responses implemented during the COVID-19 pandemic, especially regarding the associations between PHC attributes before the pandemic and dedicated care continuity responses.\u003c/p\u003e \u003cp\u003eThe Brazilian Unified Health System (SUS) is an interesting case for investigating this possible association. The SUS has continental proportions and aims to provide comprehensive healthcare to all citizens at the individual, family, and collective levels in PHC and specialized care. The SUS is under tripartite management, involving the federal, state, and municipal spheres that work together to finance and formulate health policies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The municipalities (the spheres with the least state capacity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and the greatest territorial capillarity) are responsible for most of the provided services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], especially PHC. Given the large number of municipalities, 5,570 in total [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], we observe significant internal heterogeneity in Brazilian PHC regarding the implementation of comprehensive PHC attributes.\u003c/p\u003e \u003cp\u003eThe state of S\u0026atilde;o Paulo is among the most populous in the country within the Brazilian system. It harbors 645 municipalities of different population sizes and varying levels of access to the specialized care network. It was one of the primary COVID-19 epicenters. S\u0026atilde;o Paulo\u0026rsquo;s PHC has different configurations regarding the care model adopted and has developed heterogeneous care guidelines for the pandemic [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In conjunction with these aspects, the state of S\u0026atilde;o Paulo can be taken as an interesting excerpt to constitute an analyser of the institutional care culture in Brazilian PHC, as it encompasses services in their most varied ways of implementing attributes.\u003c/p\u003e \u003cp\u003eThis study explores the influence of essential PHC attributes and local strategies for organizing actions on municipalities' performance in preserving care continuity during the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a quantitative cross-sectional study with municipal health managers due to their role in decision-making on guidelines for organizing care within PHC. The study population consisted of a probabilistic sample of municipalities in the state of São Paulo stratified by population size to allow the analysis of characteristics in different settings. Thus, the sample was drawn from three strata: (i) municipalities with 50,000 inhabitants or more (n=139); (ii) municipalities with between 10,000 and 50,000 inhabitants (n=239); and (iii) municipalities with up to 10,000 inhabitants (n=267). Stratum (i) municipalities with 50,000 inhabitants or more were surveyed in a census fashion for 139 municipalities, of which 132 participated in the study. For strata (ii) and (iii), the samples were defined using the presence of traditional PHC and ESF teams as criteria, totaling, in stratum (ii), a sample of 60 municipalities and, in (iii), a sample of 60 municipalities. In stratum (ii), 66 of the 60 planned participants and 55 of the 60 sampled participants were interviewed in stratum (iii). The three strata together generated a sample of 259 municipalities, of which 253 agreed to respond to the survey. Thus, sample losses corresponded to six municipalities and occurred due to refusal or inability to participate due to recent changes in management positions. The sample weights were calculated, and a weighted sample of 553 municipalities was obtained.\u003c/p\u003e\n\u003cp\u003eIn Brazil, the family health strategy (ESF) model is similar to that of comprehensive PHC. Thus, in this article, we refer to ESF teams as comprehensive PHCs and traditional PHC teams as representatives of services with little investment in essential PHC attributes.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData were collected from February to June 2022 through telephone or video call surveys. The form was structured on the RedCap platform and organized into seven blocks: (i) PHC model; (ii) general characteristics of PHC management in the municipality; (iii) initial adaptation to the pandemic context; (iv) COVID-19 health actions (2020 and 2021); (v) continuity of PHC activities (2020 and 2021); (vi) general impressions; and (vii) successful experiences during the pandemic. The characterization of the previous PHC structure on the basis of essential attributes was concentrated in blocks (i) and (ii); the organization of services in a health crisis was represented on the basis of the response to COVID-19, blocks (iii) and (iv); and care continuity, blocks (v), (vi) and (vii). During the questionnaire application, responses could be provided by municipal health secretaries, the PHC coordinator, the health director, or a similar position.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOn the basis of the questions in the questionnaire and the literature, we selected indicators that characterized the PHC’s level of convergence with the essential attributes (longitudinality, first contact, comprehensiveness, and care coordination) in the municipality and performance in preserving care continuity during the pandemic. In this study, we selected distinctive PHC aspects regarding the essential attributes described for this care level, which resonate with the guidelines for organizing Brazilian PHC services, considering the model [3,23,24] of ESF teams (Box 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBox 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWork process changes to adapt to the current health crisis (COVID-19) were captured through questions related to technological improvements aimed at conducting telehealth appointments [10,11] and telecare and questions related to establishing the referral flow for patients with suspected or diagnosed COVID-19 within the PHC by establishing an exclusive COVID-19 PHC service or separating PHC units exclusively for COVID-19 care. Care continuity during the pandemic was assessed through nine dimensions (Box 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBox 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the variables in the questionnaire, the potential population coverage of the existing PHC teams in the municipality and the municipality’s population were added to the analysis.\u003c/p\u003e\n\u003cp\u003eThe potential coverage of PHC teams was retrieved from the Ministry of Health’s PHC website [25], which has information on the number of funded Family Health and PHC teams, considering the potential population served by the team (data referring to the registration status in August 2021).\u003c/p\u003e\n\u003cp\u003eThe population of the municipality was obtained from the State Health Secretariat’s website [26], considering the population estimate for 2021, calculated by the SEADE Foundation, on the basis of a reprojection based on the 2022 Census. Thus, the variables included in the study were named as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComprehensive PHC:\u003c/strong\u003e Score of the convergence score with comprehensive PHC;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestment in telecare:\u0026nbsp;\u003c/strong\u003eInvestment in telecare score in PHC;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHC with flow for RS:\u0026nbsp;\u003c/strong\u003eSeparate care flows for patients with respiratory symptoms (RS) within the PHC unit;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEstablishing an exclusive COVID-19 PHC service:\u003c/strong\u003e Creating a new service to provide COVID-19 care;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusive PHC COVID-19 services:\u003c/strong\u003e Transforming a PHC service to operate as a dedicated COVID-19 care center;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare continuity in PHC:\u0026nbsp;\u003c/strong\u003ePHC care continuity score;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHC coverage:\u003c/strong\u003e Population coverage by PHC health teams;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation:\u003c/strong\u003e Number of inhabitants in the municipality.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAll the analyses were weighted on the basis of the sampling weights defined in the sampling process. The data analysis model considered care continuity in PHC as the dependent variable. Pearson’s correlation coefficient, which is based on a correlation matrix, initially measures the dependence between variables. Multiple linear regression analysis (stepwise method) was subsequently performed with all the variables of interest. A logarithmic transformation was performed to achieve a normal distribution of the population variables. The data were analysed via the SPSS\u003csup\u003eTM\u0026nbsp;\u003c/sup\u003estatistical package version 20, assuming a statistical significance level of 5%.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 shows a summary description of the variables included in this study per care continuity in PHC. In this table, we can observe a consistent association between care continuity in PHC and the variables of PHC convergence, PHC coverage, the transformation of UBS for exclusive COVID-19 care, and telecare initiatives. These variables had p\u0026lt;0.05 according to the chi-square test. The municipal population was not significantly associated with care continuity in PHC, where 40.2% of the municipalities had a population of up to 10,000, and 23.0% had a population above 50,000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Description of the variables included in the study by score of care continuity in PHC. S\u0026atilde;o Paulo State, 2022 \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare continuity in PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value *\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e00-28\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e29-39\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e40-51\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e50+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComprehensive PHC\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e00-06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e07-09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10-12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.6-and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC coverage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e00-42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.1-66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.1-and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreating a COVID-19 care center\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.476\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUp to 10,000 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,001 to 50,000 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore than 50,000 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExclusive COVID-19 PHC service\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC with care flow for RS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvestment in virtual care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedium\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Pearson correlation matrix is shown in Table 2, including all the variables selected for the study. Initially, we underscore the correlation between care continuity in PHC and PHC convergence in comprehensive PHC (r=0.453, p=0.000). Other variables were also significantly correlated but with less intensity: UBS transformation (r= -0.109, p=0.011), investment in telecare (r= 0.295, p=0.000), separate care flow in UBS for patients with respiratory symptoms (r= 0.110, p= 0.009), and PHC coverage (r= 0.111, p= 0.009). PHC coverage was also strongly correlated with population size (r= -0.662, p= 0.000).\u003c/p\u003e\n\u003cp\u003eTable 3 shows the results of the multiple linear regression analysis, where care continuity in PHC was considered the dependent variable. Convergence on the attributes of comprehensive PHC, investment in telecare, transforming the UBS into an exclusive COVID-19 PHC service, and PHC coverage were included in this model, with significant \u0026szlig; values of 0.384, 0.220, -0.136, and 0.106, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Correlation between care continuity and variables of interest. State of S\u0026atilde;o Paulo, 2022.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1006\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare continuity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComprehensive PHC attributes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation of the municipality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation of a new COVID-19 Care Center\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransformation of UBS into COVID-19 Care \u0026nbsp;Center\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInvestment in virtual care in PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeparation of care flows for patients with respiratory symptoms in the UBS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eComprehensive PHC attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.453\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.114\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eImplementation of a new COVID-19 Care Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e-0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.221\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eTransformation of UBS into COVID-19 Care \u0026nbsp;Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e-0.109\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e-0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eInvestment in virtual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.295\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.268\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.208\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.166\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eSeparation of care flows for patients with respiratory symptoms in the UBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.110\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.108\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e-0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e-0.105\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e-0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.086\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePHC Coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003ePearson\u0026rsquo;s Correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.111\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.113\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e-0.662\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e-0.151\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e-0.161\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e0.084\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7895%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4201%;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2075%;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.1221%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8173%;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6256%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3923%;\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Multiple linear regression between care continuity and associated variables. State of S\u0026atilde;o Paulo, 2022.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 351px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026szlig; (Non-Standardized)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026szlig; (Standardized)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e16.964\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eComprehensive PHC attributes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eInvestment in virtual care in PHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003eTransformation of UBS into COVID-19 Care \u0026nbsp;Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e-4.591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e-0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 261px;\"\u003e\n \u003cp\u003ePHC Coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: R\u003csup\u003e2\u003c/sup\u003e= 0.265\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study analysed PHC\u0026rsquo;s capacity to maintain routine health actions during a health crisis, such as the COVID-19 pandemic. We should discuss PHC organization in this context of crisis because system overload at all care levels has challenged the reorganization of routine appointments and preservation of care for other health problems during the pandemic [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe analysed attributes in the organization of actions in PHC to assess its potential as a comprehensive PHC. We also verified the scope of PHC prepandemic coverage in each municipality and considered strategies adopted by the municipality to address COVID-19.\u003c/p\u003e \u003cp\u003eThe results showed that PHC\u0026rsquo;s ability to maintain care continuity depended on an organizational model prioritizing comprehensive care, extended PHC population coverage, and municipal strategies for investing in PHC telecare. The municipal strategy of transforming one or more PHC services into an exclusive COVID-19 care service negatively impacted care continuity in PHC.\u003c/p\u003e \u003cp\u003eCare continuity was already a concern for PHC even before the COVID-19 pandemic [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, in the context of the pandemic, services had to be reorganized to include the new demands arising from the pandemic. The analysis of convergence on the comprehensive PHC revealed that the participation of the essential PHC attributes (longitudinality, comprehensiveness, linkage, first access, and care coordination) is structuring the organization of services, albeit with different convergence levels.\u003c/p\u003e \u003cp\u003eTherefore, the case of S\u0026atilde;o Paulo illustrates the possibility of taking the previous structure and organizational aspects of the work of PHC teams as prepandemic variables to identify the influence of comprehensive PHC on the system's response at this care level during the health crisis.\u003c/p\u003e \u003cp\u003eIn addition to this comprehensive PHC perspective, the population coverage of PHC teams enhances an adequate response to the pandemic situation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Establishing bonds of trust that encourage the use of PHC as the first access and working conditions aligned with the attributes of longitudinality, comprehensiveness, and coordination of PHC are crucial points to promote continued care even during health crises [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, the association between care continuity and establishing exclusive COVID-19 PHC services was negative. Although separating the public served between services could seemingly produce a relieving effect so that other PHC services can dedicate themselves to other demands and problems, this hypothesis was not proven true. Separating the target audience brought a rupture of the first access and comprehensiveness attributes, thus compromising longitudinality and, by extension, care continuity. In this sense, the simultaneous functioning of the attributes of comprehensive PHC is vital to preserving the care continuity effect [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, separate flows can lead to the reallocation of flows and people, affecting interprofessionality and teamwork, which also tend to harm care continuity [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], whether within or outside the context of a health crisis.\u003c/p\u003e \u003cp\u003eS\u0026atilde;o Paulo\u0026rsquo;s data align with results from the rest of Brazil [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and show the relevance of promoting comprehensive PHC and converging on this type of care organization to advance care longitudinality and territorialization, highlighted during the pandemic.\u003c/p\u003e \u003cp\u003eThe results also reinforce the idea that it is crucial to reverse the scenario of changes promoted in health systems and PHC [\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] to have health systems prepared for care continuity even during health crises, which tend to reduce financing and the scope of care and can restrictively affect the scope of care offerings and threaten the consolidation of PHC\u0026rsquo;s essential attributes.\u003c/p\u003e \u003cp\u003eConverging to comprehensive PHC was more strongly associated with care continuity than were the other variables analysed. Thus, it should gain prominence in discussions on strengthening health systems. The PHC coverage estimated in this study was based on the number of existing health teams, revealing its importance regarding the results of PHC actions, as it was significantly associated with care continuity during the pandemic period.\u003c/p\u003e \u003cp\u003eIn the national setting, the associations between a well-established PHC system with good population coverage and health outcomes for these populations are already known [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, the state of S\u0026atilde;o Paulo has shown low PHC coverage indicators over the last few decades compared with other federated units [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], with significant regional differences and a tendency towards better coverage in municipalities with smaller populations. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFollowing the example of PHC experiences in other countries, technological investments have also been made in several municipalities in Brazil to implement telecare [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] within PHC, meeting the requirements of minimizing social contact during the pandemic period. Telecare was positively associated with care continuity in PHC. However, advances in telecare must be designed to converge on PHC\u0026rsquo;s essential attributes.\u003c/p\u003e \u003cp\u003eThe Brazilian case study, with its internal diversity, shows that it is necessary to invest in expanding and consolidating the attributes of comprehensive PHC, which promotes more comprehensive and integrated care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], to strengthen PHC so that it can provide adequate responses in health crises such as the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eThere is an urgent need to implement robust policies that support the expansion of PHC in terms of its essential attributes and that encourage adaptation and healthcare continuity at all care levels to ensure the efficiency and resilience of health systems.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s limitation was its geographic scope, which adopted only one Brazilian state. However, internal diversity minimizes this aspect, which affects municipalities of different population sizes and with different health service structures. It also limited the care continuity analysis to actions related to children and pregnant women of users with NCDs, as they represent priority groups in PHC.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings presented here align with efforts already established globally to \u0026ldquo;reference\u0026rdquo; lessons learned during the COVID-19 pandemic and show the relevance of resuming discussions on the guidelines that should guide comprehensive PHC and its role in public health policies applicable to all health systems. This study reaffirms the relevance of comprehensive PHC, highlighting that its guidelines have been vital for territorialization, continuous access, and comprehensive care despite its variations. Furthermore, converging on the essential attributes of comprehensive PHC was especially crucial for care continuity. During the COVID-19 pandemic, the recovery of priority activities in PHC has shown that it is possible to maintain longitudinal actions such as prenatal care, childcare, home visits, and care for users with NCDs, even in municipalities with a smaller structure but with aspects linked to the essential attributes of comprehensive PHC.\u003c/p\u003e \u003cp\u003eTherefore, continued and robust investments in comprehensive PHC are needed to prepare the system, ensuring that health professionals deeply understand the living conditions of communities and develop a diverse range of skills and abilities. This strengthening is essential for ensuring the resilience and effectiveness of health systems in different contexts and structures. We recommend further studies detailing the implementation of PHC\u0026rsquo;s essential attributes to guide health systems in implementing comprehensive PHC.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePHC: Primary Health Care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUBS: Primary health care units\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSUS: Brazilian Unified Health System\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eESF: Family Health Strategy\u003c/p\u003e\n\u003cp\u003eRS: Respiratory Symptoms\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe data described in this article can be freely and openly accessed at Harvard Dataverse: https://doi.org/10.7910/DVN/KP7Y5A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with current ethical standards and with the approval of the Ethics Committee of the Health Institute. All participants provided informed consent prior to their involvement in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors confirm their awareness of and agreement with the submission and potential publication of this manuscript in BMC Primary Care. The parties involved, including collaborating and funding institutions, have approved the dissemination of results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data described in this article can be freely and openly accessed at Harvard Dataverse:https://doi.org/10.7910/DVN/KP7Y5A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no relevant competing interests in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by FESIMA - Health Secretariat - Government of the State of S\u0026atilde;o Paulo (Brazil). The funding agency had no role in the conception, data collection, analysis, decision to publish, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made significant contributions to the development of this study. M\u0026ocirc;nica Martins de Oliveira Viana coordinated the research and manuscript preparation. M\u0026ocirc;nica Martins de Oliveira Viana, Mariana Tarricone Garcia, L\u0026iacute;gia Schiavon Duarte, Arnaldo Sala, Maria Izabel Sanches Costa, and Michelle Fernandez contributed to data collection, analysis, and article writing. Barbara Martins Pontes managed the data repository. All authors reviewed and approved the final version of the manuscript and accept responsibility for its content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Aparecida De Albuquerque Dantas for her excellent work in field organization and data collection, and Miriam Vaz Ferreira Neves for her administrative support to the research and financial management of the project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYaacoub S, Zmeter C, Abou Abbas L, Leresche E, Kdouh O, Hammoud R, et al. Has the COVID-19 pandemic changed the utilization and provision of essential health care services from 2019 to 2020 in the primary health care network in Lebanon? Results from a nationwide representative cross-sectional survey. *PLoS One*. 2023;18(7):e0288387. doi: 10.1371/journal.pone.0288387.\u003c/li\u003e\n\u003cli\u003ePerry HB, et al. 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Cienc Saude Colet. 2023;28(12):3507-18. doi:10.1590/1413-812320232812.06302023.\u003c/li\u003e\n\u003cli\u003eVictora CG, et al. Condi\u0026ccedil;\u0026otilde;es de sa\u0026uacute;de e inova\u0026ccedil;\u0026otilde;es nas pol\u0026iacute;ticas de sa\u0026uacute;de no Brasil: o caminho a percorrer. The Lancet. 2011;90-102. Available from: https://www.thelancet.com/pb/assets/raw/Lancet//pdfs/brazil/brazilpor6.pdf\u003c/li\u003e\n\u003cli\u003eEvans PB, Rueschemeyer D, Skocpol T, editors. Bringing the State Back In. Cambridge: Cambridge University Press; 1985.\u003c/li\u003e\n\u003cli\u003eNoronha JC, Lima LD, Machado CV. O Sistema \u0026Uacute;nico de Sa\u0026uacute;de \u0026ndash; SUS. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, editors. Pol\u0026iacute;ticas e Sistema de Sa\u0026uacute;de no Brasil. 2nd ed. Rio de Janeiro: Fiocruz; 2012.\u003c/li\u003e\n\u003cli\u003eInstituto Brasileiro de Geografia e Estat\u0026iacute;stica (IBGE). Atualiza\u0026ccedil;\u0026atilde;o dos Mapas Municipais e \u0026Aacute;reas Territoriais de estados e Munic\u0026iacute;pio. 2022.\u003c/li\u003e\n\u003cli\u003eCastanheira ERL, et al. Organiza\u0026ccedil;\u0026atilde;o da aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria \u0026agrave; sa\u0026uacute;de de munic\u0026iacute;pios de S\u0026atilde;o Paulo, Brasil: modelo de aten\u0026ccedil;\u0026atilde;o e coer\u0026ecirc;ncia com as diretrizes do Sistema \u0026Uacute;nico de Sa\u0026uacute;de. Cadernos Saude Publica. 2024;40(2):PT099723. doi:10.1590/0102-311XPT099723.\u003c/li\u003e\n\u003cli\u003eSchenkman S, et al. Padr\u0026otilde;es de desempenho da aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria \u0026agrave; sa\u0026uacute;de diante da COVID-19 no Brasil: caracter\u0026iacute;sticas e contrastes. Cadernos Saude Publica. 2024;39(8):e00009123. doi:10.1590/0102-311XPT009123.\u003c/li\u003e\n\u003cli\u003eMinist\u0026eacute;rio da Sa\u0026uacute;de. E-gestor Aten\u0026ccedil;\u0026atilde;o B\u0026aacute;sica: financiamento da APS. Available from: https://egestorab.saude.gov.br/gestaoaps/relFinanciamento.xhtml.\u003c/li\u003e\n\u003cli\u003eSecretaria de Estado da Sa\u0026uacute;de (SP). Informa\u0026ccedil;\u0026otilde;es de sa\u0026uacute;de: indicadores de sa\u0026uacute;de. Available from: https://www.saude.sp.gov.br/ses/perfil/profissional-da-saude/informacoes-de-saude-/tabnet-ses-indicadores-de-saude.\u003c/li\u003e\n\u003cli\u003eSoares DA, Kochergin CN, Mistro S, Macedo JCL, Carvalho VCH dos S de, Oliveira MG. Aten\u0026ccedil;\u0026atilde;o Prim\u0026aacute;ria \u0026agrave; Sa\u0026uacute;de abrangente: an\u0026aacute;lise a partir do trabalho das equipes de Sa\u0026uacute;de da Fam\u0026iacute;lia frente \u0026agrave;s doen\u0026ccedil;as cr\u0026ocirc;nicas. Physis [Internet]. 2024;34:e34015. Available from: https://doi.org/10.1590/S0103-7331202434015pt\u003c/li\u003e\n\u003cli\u003eViacava F, et al. SUS: oferta, acesso e utiliza\u0026ccedil;\u0026atilde;o de servi\u0026ccedil;os de sa\u0026uacute;de nos \u0026uacute;ltimos 30 anos. Cienc Saude Colet. 2018;23(6):1751-62. doi:10.1590/1413-81232018236.06022018.\u003c/li\u003e\n\u003cli\u003eMayo AT. Teamwork in a pandemic: insights from management research BMJ Leader 2020;4:53-56. doi:10.1136/LEADER-2020-000246.\u003c/li\u003e\n\u003cli\u003eEngstrom E, Teixeira MB, Oliveira R, Vianna SM, Gon\u0026ccedil;alves AS. Recomenda\u0026ccedil;\u0026otilde;es para a organiza\u0026ccedil;\u0026atilde;o da aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria \u0026agrave; sa\u0026uacute;de no SUS no enfrentamento da Covid-19. Observat\u0026oacute;rio Covid-19: S\u0026eacute;rie Linda de cuidado Covid-19 na Rede de Aten\u0026ccedil;\u0026atilde;o \u0026agrave; Sa\u0026uacute;de. Rio de Janeiro: Fiocruz; 2020.\u003c/li\u003e\n\u003cli\u003eCordilha, A. C., \u0026amp; Lavinas, L.. (2018). 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Cadernos De Sa\u0026uacute;de P\u0026uacute;blica, 32(8), e00034716. https://doi.org/10.1590/0102-311X00034716\u003c/li\u003e\n\u003cli\u003ePaim JS. Sistema \u0026Uacute;nico de Sa\u0026uacute;de (SUS) aos 30 anos. Ci\u0026ecirc;nc sa\u0026uacute;de coletiva [Internet]. 2018Jun;23(6):1723\u0026ndash;8. Available from: https://doi.org/10.1590/1413-81232018236.09172018\u003c/li\u003e\n\u003cli\u003eBrand\u0026atilde;o JR de M. A aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria \u0026agrave; sa\u0026uacute;de no Canad\u0026aacute;: realidade e desafios atuais. Cad Sa\u0026uacute;de P\u0026uacute;blica [Internet]. 2019;35(1):e00178217. Available from: https://doi.org/10.1590/0102-311X00178217\u003c/li\u003e\n\u003cli\u003eGiovanella L, Franco CM, Almeida PF. Pol\u0026iacute;tica Nacional de Aten\u0026ccedil;\u0026atilde;o B\u0026aacute;sica: para onde vamos? Ci\u0026ecirc;nc Sa\u0026uacute;de Coleta [Internet]. 2020;25(4):1475-82. doi: 10.1590/1413-81232020254.01842020.\u003c/li\u003e\n\u003cli\u003eMacinko J, Mendon\u0026ccedil;a CS. Estrat\u0026eacute;gia Sa\u0026uacute;de da Fam\u0026iacute;lia, um forte modelo de Aten\u0026ccedil;\u0026atilde;o Prim\u0026aacute;ria \u0026agrave; Sa\u0026uacute;de que traz resultados. \u003cem\u003eSa\u0026uacute;de Debate\u003c/em\u003e. 2018;42(Spec 1):18-37. doi: 10.1590/0103-11042018S102.\u003c/li\u003e\n\u003cli\u003eDaumas RP, Silva GA e, Tasca R, Leite I da C, Brasil P, Greco DB, et al.. O papel da aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria na rede de aten\u0026ccedil;\u0026atilde;o \u0026agrave; sa\u0026uacute;de no Brasil: limites e possibilidades no enfrentamento da COVID-19. Cad Sa\u0026uacute;de P\u0026uacute;blica [Internet]. 2020;36(6):e00104120. Available from: https://doi.org/10.1590/0102-311X00104120\u003c/li\u003e\n\u003cli\u003eGiovanella L, Bousquat A, Schenkman S, Almeida PF, Sardinha LMV, Vieira MLFP. Cobertura da Estrat\u0026eacute;gia Sa\u0026uacute;de da Fam\u0026iacute;lia no Brasil: o que nos mostram as Pesquisas Nacionais de Sa\u0026uacute;de 2013 e 2019. \u003cem\u003eCi\u0026ecirc;nc Sa\u0026uacute;de Colet\u003c/em\u003e. 2021;26(Suppl 1):2543-56. doi: 10.1590/1413-81232021266.1.43952020.\u003c/li\u003e\n\u003cli\u003eBrasil. Minist\u0026eacute;rio da Sa\u0026uacute;de. e-Gestor Aten\u0026ccedil;\u0026atilde;o Prim\u0026aacute;ria \u0026agrave; Sa\u0026uacute;de - Relat\u0026oacute;rios APS - Cobertura Potencial da APS (2021 - atual). Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Box","content":"\u003cp\u003e\u003cstrong\u003eBox 1. Aspects considered for scoring the convergence score with the comprehensive PHC.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAspects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore variation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eTerritorialization process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eGuidance on access to PHC offered to users\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e2 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eContinuity of care by the same team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e0 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eMedical care provided by a family doctor or general practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e0 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eActivities performed by community health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e0 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 72.6667%;\"\u003e\n \u003cp\u003eAvailable counter-referral flow between health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.3333%;\"\u003e\n \u003cp\u003e1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eBox 2. Aspects considered for scoring care continuity during the COVID-19 pandemic.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"626\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAspects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore variation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eHome visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e-1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eActivities performed by PHC during home visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e0 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003ePrenatal care appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e-1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eActivities performed by PHC during prenatal care appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eChildcare\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e-1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eActivities performed by PHC during childcare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eAppointments for chronic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e-1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eActivities performed by PHC during appointments for chronic diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e1 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.8019%;\"\u003e\n \u003cp\u003eParticipants\u0026apos; self-assessment of their performance in providing care continuity for priority groups (pregnant women, children aged 0-2 years, and people with chronic diseases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1981%;\"\u003e\n \u003cp\u003e0 to 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary health care, Health systems, Health services, Healthcare models, Comprehensive health care, Continuity of patient care, Brazil, COVID-19","lastPublishedDoi":"10.21203/rs.3.rs-5369192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5369192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Primary health care (PHC) is essential for achieving universal health coverage, especially in low- and middle-income countries, where it has been associated with curbing health inequalities and providing financial protection. It is distinguished from other care levels by its essential attributes: longitudinality, first-contact care, comprehensiveness, and care coordination across the network. PHCs played a crucial role during the COVID-19 pandemic, and providing continuous care while coordinating testing and contact tracing was challenging. It is necessary to adapt its operations to ensure care. This study explores the influence of essential PHC attributes and local organizational strategies on care continuity during the pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A quantitative cross-sectional study was conducted with health managers from municipalities in the state of São Paulo in a sample stratified by population size. The survey was applied in 259 municipalities, and the weighted analysis considered 553 municipalities. We evaluated indicators related to care continuity in PHC, convergence with essential PHC attributes, local strategies such as telecare, and the adaptation of PHC units (UBSs) to an exclusive COVID-19 PHC service. Statistical analyses included Pearson’s correlation and multiple linear regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Care continuity in PHC was significantly associated with convergence of essential PHC attributes (r=0.453, p=0.000), PHC coverage, investment in telecare, and the transformation of UBS to care exclusively for COVID-19 patients. The regression model revealed that these variables significantly influenced care maintenance during the pandemic, and convergence of essential PHC attributes was the most relevant factor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Convergence in the essential attributes of comprehensive PHC was crucial for care continuity during the pandemic. Owing to the essential attributes of comprehensive PHC, continued strengthening of PHC is necessary to ensure the resilience of health systems, and we recommend future studies on the implementation of the essential attributes of comprehensive PHC.\u003c/p\u003e","manuscriptTitle":"Primary Care and Care Continuity in the Context of a Health Crisis: Lessons Learned from the Brazilian Reality","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 06:20:37","doi":"10.21203/rs.3.rs-5369192/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-06T05:05:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-04T07:56:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-04T07:55:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-10-31T20:52:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0200e42-f1f3-419a-8d93-3249adf1dc26","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:00:35+00:00","versionOfRecord":{"articleIdentity":"rs-5369192","link":"https://doi.org/10.1186/s12875-026-03296-4","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2026-04-09 15:57:37","publishedOnDateReadable":"April 9th, 2026"},"versionCreatedAt":"2024-11-15 06:20:37","video":"","vorDoi":"10.1186/s12875-026-03296-4","vorDoiUrl":"https://doi.org/10.1186/s12875-026-03296-4","workflowStages":[]},"version":"v1","identity":"rs-5369192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5369192","identity":"rs-5369192","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}